Provider Demographics
NPI:1417616335
Name:LUTZ, JILL (MA LLP)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:
Last Name:LUTZ
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:MRS
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:LUTZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA LLP
Mailing Address - Street 1:363 W BIG BEAVER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-5380
Mailing Address - Country:US
Mailing Address - Phone:248-509-7657
Mailing Address - Fax:248-509-7658
Practice Address - Street 1:363 W BIG BEAVER RD STE 200
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-5380
Practice Address - Country:US
Practice Address - Phone:248-509-7657
Practice Address - Fax:248-509-7658
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361004210103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6361004210Other6361004210