Provider Demographics
NPI:1053622522
Name:KUTZEN, STEPHANIE LYNN (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:LYNN
Last Name:KUTZEN
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:LYNN
Other - Last Name:WEINSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD, LCSW
Mailing Address - Street 1:1925 LAKE AVENUE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091
Mailing Address - Country:US
Mailing Address - Phone:847-256-1111
Mailing Address - Fax:847-251-3081
Practice Address - Street 1:1925 LAKE AVENUE
Practice Address - Street 2:SUITE 305
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091
Practice Address - Country:US
Practice Address - Phone:847-256-1111
Practice Address - Fax:847-251-3081
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.003367104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL#201107Medicare PIN