Provider Demographics
NPI:1477339158
Name:LUTZ, KALLIE
Entity Type:Individual
Prefix:
First Name:KALLIE
Middle Name:
Last Name:LUTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 276
Mailing Address - Street 2:
Mailing Address - City:TOWNSEND
Mailing Address - State:DE
Mailing Address - Zip Code:19734-0276
Mailing Address - Country:US
Mailing Address - Phone:484-338-0082
Mailing Address - Fax:
Practice Address - Street 1:365 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-1010
Practice Address - Country:US
Practice Address - Phone:302-653-8589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool