Provider Demographics
NPI:1558583203
Name:LOTZ, DEBRA JEAN
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:JEAN
Last Name:LOTZ
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 1:1572 N MOUNT ZION RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-6059
Mailing Address - Country:US
Mailing Address - Phone:217-473-0278
Mailing Address - Fax:
Practice Address - Street 1:1572 N MOUNT ZION RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-6059
Practice Address - Country:US
Practice Address - Phone:217-473-0278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILDL38640602P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL007OtherDEVELOPMENTAL THERAPIST