Provider Demographics
NPI:1770502247
Name:KOGUTEK, MICHAEL DENNIS (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DENNIS
Last Name:KOGUTEK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:DENNIS
Other - Last Name:KOGUTEK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:17291 IRVINE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2930
Mailing Address - Country:US
Mailing Address - Phone:714-973-7621
Mailing Address - Fax:714-368-3302
Practice Address - Street 1:17291 IRVINE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2930
Practice Address - Country:US
Practice Address - Phone:714-973-7621
Practice Address - Fax:714-368-3302
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5975103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical