Provider Demographics
NPI:1518569441
Name:LUTZ, JON RICHARD
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:RICHARD
Last Name:LUTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20670 HOOVER BAULT RD
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-9258
Mailing Address - Country:US
Mailing Address - Phone:937-707-0433
Mailing Address - Fax:
Practice Address - Street 1:20670 HOOVER BAULT RD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-9258
Practice Address - Country:US
Practice Address - Phone:937-707-0433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No252Y00000XAgenciesEarly Intervention Provider Agency