Provider Demographics
NPI:1972196467
Name:LUTZ, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LUTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N 17TH ST APT 406
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-2666
Mailing Address - Country:US
Mailing Address - Phone:732-272-2875
Mailing Address - Fax:
Practice Address - Street 1:751 ROUTE 73 N STE 1
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3456
Practice Address - Country:US
Practice Address - Phone:856-375-2914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist