Provider Demographics
NPI:1043383235
Name:NUTTER, KENNETH MICHAEL (PHD, LMHC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:NUTTER
Suffix:
Gender:M
Credentials:PHD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 CENTER RD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-4803
Mailing Address - Country:US
Mailing Address - Phone:941-375-5222
Mailing Address - Fax:941-460-5109
Practice Address - Street 1:230 TAMIAMI TRL S
Practice Address - Street 2:SUITE 3
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2453
Practice Address - Country:US
Practice Address - Phone:941-375-5222
Practice Address - Fax:941-460-5109
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 5058101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767676000Medicaid