Provider Demographics
NPI:1518336411
Name:LUTZEN-MEDINA, SANDRA (LMT, WHE)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:LUTZEN-MEDINA
Suffix:
Gender:F
Credentials:LMT, WHE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 NADWORNY LN
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2100
Mailing Address - Country:US
Mailing Address - Phone:631-678-2122
Mailing Address - Fax:
Practice Address - Street 1:17 NADWORNY LN
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2100
Practice Address - Country:US
Practice Address - Phone:631-678-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-21
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010705-1174H00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist