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General NPI Number Information
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NPI Number | 1588020846
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Entity Type | Individual
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Provider Name | MR. PHILLIP THOMAS LUTTRELL
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Gender | Male
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Dates
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Enumeration Date | 01/01/2016
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Last Update Date | 02/21/2024
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Provider Practice Location Address
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Address Line | 100 ORNDORF DR UNIT 1326
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City | BRIGHTON
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State | MI
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Zip | 48116-7057
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Country | US
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Telephone | 248-491-8447
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Fax |
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Provider Business Mailing Address
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Address Line | 9600 MARSHALL RD
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City | SOUTH LYON
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State | MI
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Zip | 48178-8879
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Country | US
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Telephone | 989-413-9115
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | L364683792106
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | L364683792106
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801103889
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License Number State | MI
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