=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255822839
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICHMOND AND LUTTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2018
-----------------------------------------------------
Last Update Date | 05/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 312 MORTON AVE
-----------------------------------------------------
City | RIDLEY PARK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19078-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-437-2991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 312 MORTON AVE
-----------------------------------------------------
City | RIDLEY PARK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19078-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LEAD CLINICIAN
-----------------------------------------------------
Name | TIIU LUTTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 484-437-2991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MF000790
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------