Provider Demographics
NPI:1710616305
Name:LUTY, KANDY ANN (LAC)
Entity Type:Individual
Prefix:
First Name:KANDY
Middle Name:ANN
Last Name:LUTY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22713 S ELLSWORTH RD STE A101
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-7886
Mailing Address - Country:US
Mailing Address - Phone:480-445-0938
Mailing Address - Fax:
Practice Address - Street 1:22713 S ELLSWORTH RD STE A101
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-7886
Practice Address - Country:US
Practice Address - Phone:480-445-0938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
AZLAC-20016101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health