Provider Demographics
NPI:1346355088
Name:LUETZOW, JOHN D (PH D)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:LUETZOW
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 BETHLEHEM PIKE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ERDENHEIM
Mailing Address - State:PA
Mailing Address - Zip Code:19038-8110
Mailing Address - Country:US
Mailing Address - Phone:215-836-1582
Mailing Address - Fax:
Practice Address - Street 1:808 BETHLEHEM PIKE
Practice Address - Street 2:SUITE 5
Practice Address - City:ERDENHEIM
Practice Address - State:PA
Practice Address - Zip Code:19038-8110
Practice Address - Country:US
Practice Address - Phone:215-836-1582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS008042L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
821011Medicare ID - Type Unspecified