Provider Demographics
NPI:1609606524
Name:DUTENHAFER, LANCE
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:DUTENHAFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 OAK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6408
Mailing Address - Country:US
Mailing Address - Phone:847-465-9556
Mailing Address - Fax:
Practice Address - Street 1:7177 CRIMSON RIDGE DR STE 10
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6235
Practice Address - Country:US
Practice Address - Phone:847-465-9556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-24-360456106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician