Provider Demographics
NPI:1952533135
Name:LUTTENBACHER, KURT JACK (LPC, LCAS)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:JACK
Last Name:LUTTENBACHER
Suffix:
Gender:M
Credentials:LPC, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N MAIN ST STE 600
Mailing Address - Street 2:P.O. BOX 6023
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-3867
Mailing Address - Country:US
Mailing Address - Phone:336-957-8508
Mailing Address - Fax:
Practice Address - Street 1:201 N MAIN ST STE 600
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-3867
Practice Address - Country:US
Practice Address - Phone:336-452-4366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7427101Y00000X, 101YM0800X, 101YP2500X
NC1606101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)