Provider Demographics
NPI:1538195987
Name:KUTTNER, MICHAEL JOHN (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:KUTTNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:448 WHITE SPRUCE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1608
Mailing Address - Country:US
Mailing Address - Phone:585-256-3440
Mailing Address - Fax:
Practice Address - Street 1:990 SOUTH AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2740
Practice Address - Country:US
Practice Address - Phone:585-256-3440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009564103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY100295AHOtherPREFERRED CARE
NYP010009564OtherBLUE CHOICE
NY111980500OtherUS DEPT OF LABOR
P010009564OtherBLUE X/BLUE SHIELD
NY10849BMedicare ID - Type UnspecifiedMEIDICARE