Healthcare Provider Details

I. General information

NPI: 1790093169
Provider Name (Legal Business Name): LISA KUTZ LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2010
Last Update Date: 09/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 E LOUCKS ST SUITE 209
SHERIDAN WY
82801-6339
US

IV. Provider business mailing address

PO BOX 1035
SHERIDAN WY
82801-1035
US

V. Phone/Fax

Practice location:
  • Phone: 307-674-5123
  • Fax:
Mailing address:
  • Phone: 307-674-5123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT-153
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: