Provider Demographics
NPI:1497152227
Name:NUTTLE, DIRK (LPCA, LCAS-A, CRC)
Entity Type:Individual
Prefix:
First Name:DIRK
Middle Name:
Last Name:NUTTLE
Suffix:
Gender:M
Credentials:LPCA, LCAS-A, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6324 STONEWICK DR
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-8516
Mailing Address - Country:US
Mailing Address - Phone:336-707-6825
Mailing Address - Fax:
Practice Address - Street 1:6324 STONEWICK DR
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NC
Practice Address - Zip Code:27282-8516
Practice Address - Country:US
Practice Address - Phone:336-707-6825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-20573101YA0400X
NCA10631101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health