=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003883406
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL L STUTTS PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2006
-----------------------------------------------------
Last Update Date | 12/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 FAIRFAX AVE STE 710
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23507-1914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-446-5888
-----------------------------------------------------
Fax | 757-446-5918
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 936
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23501-0936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-446-8400
-----------------------------------------------------
Fax | 757-446-8401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 08010001340
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------