Provider Demographics
NPI:1588020846
Name:LUTTRELL, PHILLIP THOMAS
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:THOMAS
Last Name:LUTTRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 MARSHALL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-8879
Mailing Address - Country:US
Mailing Address - Phone:989-413-9115
Mailing Address - Fax:
Practice Address - Street 1:100 ORNDORF DR UNIT 1326
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-7057
Practice Address - Country:US
Practice Address - Phone:248-491-8447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-01
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL364683792106101YA0400X, 101YM0800X
MI68011038891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health