Provider Demographics
NPI:1881684777
Name:LUTZ, STEVEN (PSYD, LP)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:LUTZ
Suffix:
Gender:M
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8669 EAGLE POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-8628
Mailing Address - Country:US
Mailing Address - Phone:651-379-0444
Mailing Address - Fax:651-379-0448
Practice Address - Street 1:8669 EAGLE POINT BLVD
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-8628
Practice Address - Country:US
Practice Address - Phone:651-379-0444
Practice Address - Fax:651-379-0448
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4421103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN463725OtherVALUE OPTIONS
MN468166000OtherMAGELLAN/AETNA ID#
MN336R2LUOtherBCBS ID#
MN450620100Medicaid
MNHP55874OtherHEALTH PARTNERS ID#
MN172007OtherBHP/FAIRVIEW/PREFERRED 1
MN55042A004OtherTRICARE/TRIWEST
MN680001873Medicare ID - Type Unspecified