Provider Demographics
NPI:1235472580
Name:LUTZ, ROBERTA ISAACSON
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:ISAACSON
Last Name:LUTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:MARION
Other - Last Name:ISAACSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3892 KEILY DR
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-2004
Mailing Address - Country:US
Mailing Address - Phone:516-781-2239
Mailing Address - Fax:
Practice Address - Street 1:3892 KEILY DR
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-2004
Practice Address - Country:US
Practice Address - Phone:516-781-2239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist