Provider Demographics
NPI:1932962214
Name:KUTZER, DOUGLAS THOMAS (LSW)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:THOMAS
Last Name:KUTZER
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61102-2112
Mailing Address - Country:US
Mailing Address - Phone:815-490-1600
Mailing Address - Fax:815-490-1881
Practice Address - Street 1:1200 W STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61102-2112
Practice Address - Country:US
Practice Address - Phone:815-490-1600
Practice Address - Fax:815-490-1881
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150111792104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker