Provider Demographics
NPI:1053628248
Name:HUTNER, KELLY STEWART (PSYD, HSPP)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:STEWART
Last Name:HUTNER
Suffix:
Gender:F
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 NEW VISION DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11143 PARKVIEW PLAZA DR STE 320
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1728
Practice Address - Country:US
Practice Address - Phone:260-266-5370
Practice Address - Fax:260-266-5379
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041507A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical