Provider Demographics
NPI:1013327055
Name:LOSTUTTER, TY W (PHD)
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:W
Last Name:LOSTUTTER
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 1:4225 ROOSEVELT WAY NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-6099
Mailing Address - Country:US
Mailing Address - Phone:206-598-7792
Mailing Address - Fax:
Practice Address - Street 1:4225 ROOSEVELT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-6099
Practice Address - Country:US
Practice Address - Phone:206-598-7792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY 60238397103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical