Provider Demographics
NPI:1114158227
Name:LUTZ, JOSHUA ANTHONY (ED,S, NCSP)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:ANTHONY
Last Name:LUTZ
Suffix:
Gender:M
Credentials:ED,S, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 BAY BRIDGE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4468
Mailing Address - Country:US
Mailing Address - Phone:866-960-8806
Mailing Address - Fax:866-960-8806
Practice Address - Street 1:91 BAY BRIDGE DR
Practice Address - Street 2:SUITE D
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4468
Practice Address - Country:US
Practice Address - Phone:866-960-8806
Practice Address - Fax:866-960-8806
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS795103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11997743OtherCAQH