Provider Demographics
NPI:1699936260
Name:LUTTRELL, MARK D (DPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:LUTTRELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-2342
Mailing Address - Country:US
Mailing Address - Phone:785-331-0106
Mailing Address - Fax:785-331-0107
Practice Address - Street 1:535 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-2342
Practice Address - Country:US
Practice Address - Phone:785-331-0106
Practice Address - Fax:785-331-0107
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-02013225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist