Basic Information
| Provider Information | |||||||||
| NPI: | 1861513657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUTILLE | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7901 BROADWAY | ||||||||
| Address2: | MANAGED CARE D1-01 | ||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183341921 | ||||||||
| FaxNumber: | 7183343432 | ||||||||
| Practice Location | |||||||||
| Address1: | 80TH ST & 41ST AVE | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183343900 | ||||||||
| FaxNumber: | 7183345958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 034055 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 00246075 | 05 | NY | MEDICAID |