Provider Demographics
NPI:1336296276
Name:STUTZMAN, PHYLLIS D (MSW)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:D
Last Name:STUTZMAN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:D
Other - Last Name:STUTZMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:307 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-3715
Mailing Address - Country:US
Mailing Address - Phone:574-534-9099
Mailing Address - Fax:574-534-5530
Practice Address - Street 1:307 S 5TH ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-3715
Practice Address - Country:US
Practice Address - Phone:574-534-9099
Practice Address - Fax:574-534-5530
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000681A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000001755979Medicare UPIN
4276676Medicare UPIN