Provider Demographics
NPI:1891931895
Name:LUTZ, SHANNON RAE (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RAE
Last Name:LUTZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15735 W US HIGHWAY 63
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-6475
Mailing Address - Country:US
Mailing Address - Phone:715-934-0710
Mailing Address - Fax:715-598-4881
Practice Address - Street 1:115 5TH AVE N
Practice Address - Street 2:
Practice Address - City:HURLEY
Practice Address - State:WI
Practice Address - Zip Code:54534-1208
Practice Address - Country:US
Practice Address - Phone:153-291-2887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-21
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010905521041C0700X
WI101761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical