Provider Demographics
NPI:1902372568
Name:LUTZ, ELIZABETH MARIE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:LUTZ
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 DEER RUN APT 106
Mailing Address - Street 2:
Mailing Address - City:COTULLA
Mailing Address - State:TX
Mailing Address - Zip Code:78014-2034
Mailing Address - Country:US
Mailing Address - Phone:830-426-0255
Mailing Address - Fax:
Practice Address - Street 1:310 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:COTULLA
Practice Address - State:TX
Practice Address - Zip Code:78014
Practice Address - Country:US
Practice Address - Phone:830-879-2374
Practice Address - Fax:830-879-4343
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT64262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty