Provider Demographics
NPI:1689047730
Name:KUTNAR, KEITH AARON (PSYD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:AARON
Last Name:KUTNAR
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 MANCHESTER RD
Mailing Address - Street 2:SUITE 1510
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-4579
Mailing Address - Country:US
Mailing Address - Phone:630-653-1717
Mailing Address - Fax:630-344-1087
Practice Address - Street 1:1420 AUSTIN BLUFFS PKWY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3733
Practice Address - Country:US
Practice Address - Phone:719-255-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-10
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.011414101YM0800X
CO0006035103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health