Healthcare Provider Details

I. General information

NPI: 1689313058
Provider Name (Legal Business Name): LARRY KUTAY LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 15TH ST
WHEELING WV
26003-3548
US

IV. Provider business mailing address

87 15TH ST
WHEELING WV
26003-3548
US

V. Phone/Fax

Practice location:
  • Phone: 304-233-9627
  • Fax:
Mailing address:
  • Phone: 304-233-9627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberAP00942054
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: