Basic Information
Provider Information | |||||||||
NPI: | 1003883406 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STUTTS | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 936 | ||||||||
Address2: |   | ||||||||
City: | NORFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 235010936 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7574468400 | ||||||||
FaxNumber: | 7574468401 | ||||||||
Practice Location | |||||||||
Address1: | 825 FAIRFAX AVE STE 710 | ||||||||
Address2: |   | ||||||||
City: | NORFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 235071914 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7574465888 | ||||||||
FaxNumber: | 7574465918 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/03/2006 | ||||||||
LastUpdateDate: | 12/29/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 08010001340 | VA | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 000496 | 01 | VA | VALUE OPTIONS | OTHER | PAR | 01 | VA | USA MANAGED CARE | OTHER | PAR | 01 | VA | FIRST HEALTH COMMERCIAL | OTHER | 007700245 | 05 | VA |   | MEDICAID | 0367K | 01 | NC | BC/BS | OTHER | PAR | 01 | VA | AETNA | OTHER | 255618 | 01 | VA | MAGELLAN HEALTH SERVICES | OTHER | 343838 | 01 | VA | MANAGED HEALTH NETWORK | OTHER | PAR | 01 | VA | MULTIPLAN | OTHER | PAR | 01 | VA | CORVEL/CORCARE | OTHER | 215684 | 01 | VA | UNITED HEALTH CARE/MAMSI | OTHER | -006 | 01 | VA | TRICARE/CHAMPUS | OTHER | 081903 | 01 | VA | ANTHEM | OTHER | 88854 | 01 | VA | SENTARA/OPTIMA | OTHER | PAR | 01 | VA | VIRGINIA PREMIER HEALTH | OTHER | PAR | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER |