Provider Demographics
NPI:1912135716
Name:LUTSES, MARK (SPL/TSHH)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:LUTSES
Suffix:
Gender:M
Credentials:SPL/TSHH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 COLFAX AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-3364
Mailing Address - Country:US
Mailing Address - Phone:718-290-3561
Mailing Address - Fax:718-668-0864
Practice Address - Street 1:145 COLFAX AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-3364
Practice Address - Country:US
Practice Address - Phone:718-290-3561
Practice Address - Fax:718-668-0864
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014554-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist