Provider Demographics
NPI:1376694455
Name:LUTZOW, NIKKI M (PT)
Entity Type:Individual
Prefix:MRS
First Name:NIKKI
Middle Name:M
Last Name:LUTZOW
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 GRAND RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-1074
Mailing Address - Country:US
Mailing Address - Phone:630-443-9223
Mailing Address - Fax:
Practice Address - Street 1:525 TYLER RD STE Q1
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-3360
Practice Address - Country:US
Practice Address - Phone:630-444-0077
Practice Address - Fax:630-444-0078
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700122592251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics