Provider Demographics
NPI:1407374911
Name:LUTZ, BLAKE JOHN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:JOHN
Last Name:LUTZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 LANDON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NEW HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27562-9305
Mailing Address - Country:US
Mailing Address - Phone:919-593-5500
Mailing Address - Fax:
Practice Address - Street 1:2925 LANDON RIDGE DR
Practice Address - Street 2:
Practice Address - City:NEW HILL
Practice Address - State:NC
Practice Address - Zip Code:27562-2756
Practice Address - Country:US
Practice Address - Phone:919-593-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0076511041C0700X
NJ44SC054893001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical