Provider Demographics
NPI:1972745222
Name:DUTHLER, BERNARD THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:THOMAS
Last Name:DUTHLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 28TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-2849
Mailing Address - Country:US
Mailing Address - Phone:616-453-5491
Mailing Address - Fax:616-774-0024
Practice Address - Street 1:830 28TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-2849
Practice Address - Country:US
Practice Address - Phone:616-453-5491
Practice Address - Fax:616-774-0024
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301001075103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D14537Medicare PIN