Provider Demographics
NPI:1396719209
Name:LUTTRELL, MICHAEL J (LICENSED PSYCHOLOGIS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:LUTTRELL
Suffix:
Gender:M
Credentials:LICENSED PSYCHOLOGIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 BRENTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MARSHALLTOWN
Mailing Address - State:IA
Mailing Address - Zip Code:50158-3726
Mailing Address - Country:US
Mailing Address - Phone:641-752-0125
Mailing Address - Fax:
Practice Address - Street 1:9 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:MARSHALLTOWN
Practice Address - State:IA
Practice Address - Zip Code:50158-1836
Practice Address - Country:US
Practice Address - Phone:641-752-1585
Practice Address - Fax:641-752-9665
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00420103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0058230Medicaid
IA05823OtherBCBS
IA037093OtherHEALTH ALLIANCE
IA0058230Medicaid