Provider Demographics
NPI:1235450230
Name:HATMAKER-LUTZ, ELISA SUNSHINE (MA)
Entity Type:Individual
Prefix:MRS
First Name:ELISA
Middle Name:SUNSHINE
Last Name:HATMAKER-LUTZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8888
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-0888
Mailing Address - Country:US
Mailing Address - Phone:304-395-1850
Mailing Address - Fax:
Practice Address - Street 1:900 6TH AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-2921
Practice Address - Country:US
Practice Address - Phone:304-395-1850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-14
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV996103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810022109Medicaid