Provider Demographics
NPI:1508986852
Name:LUTZ, MARK W (LPC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:W
Last Name:LUTZ
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 N ARIZONA BLVD, SUITE D
Mailing Address - Street 2:
Mailing Address - City:COOLIDGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85128-5800
Mailing Address - Country:US
Mailing Address - Phone:480-580-4036
Mailing Address - Fax:
Practice Address - Street 1:102 N ARIZONA BLVD, SUITE D
Practice Address - Street 2:
Practice Address - City:COOLIDGE
Practice Address - State:AZ
Practice Address - Zip Code:85128-5800
Practice Address - Country:US
Practice Address - Phone:480-580-4036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-1981101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ724014Medicaid