Provider Demographics
NPI:1659673879
Name:LUTZ, KRISTIN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:LUTZ
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NE 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-6812
Mailing Address - Country:US
Mailing Address - Phone:360-952-3651
Mailing Address - Fax:360-906-1010
Practice Address - Street 1:2500 NE 65TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-6812
Practice Address - Country:US
Practice Address - Phone:360-952-3651
Practice Address - Fax:360-906-1010
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60188190235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7018120Medicaid