Provider Demographics
NPI:1225611825
Name:LUTZ, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:LUTZ
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 1:31889 VIA DEL PASO
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596-8603
Mailing Address - Country:US
Mailing Address - Phone:502-500-8419
Mailing Address - Fax:
Practice Address - Street 1:31889 VIA DEL PASO
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:CA
Practice Address - Zip Code:92596-8603
Practice Address - Country:US
Practice Address - Phone:502-500-8419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA929691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical