Provider Demographics
NPI:1508844135
Name:KUTINAC, JOHN G JR (MA PA LPCC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:G
Last Name:KUTINAC
Suffix:JR
Gender:M
Credentials:MA PA LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1155 S TELSHOR BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-1009
Mailing Address - Country:US
Mailing Address - Phone:505-522-8002
Mailing Address - Fax:505-522-8027
Practice Address - Street 1:1155 S TELSHOR BLVD
Practice Address - Street 2:STE 200
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-1009
Practice Address - Country:US
Practice Address - Phone:505-522-8002
Practice Address - Fax:505-522-8027
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA9501103T00000X
NM1157101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM27146Medicaid