Provider Demographics
NPI:1972856623
Name:LUTZ, MICHAEL T (COTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:LUTZ
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1570 PASEO GRANDE
Mailing Address - Street 2:APT 2011
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-8523
Mailing Address - Country:US
Mailing Address - Phone:715-292-8785
Mailing Address - Fax:
Practice Address - Street 1:2150 SILVER CREEK RD
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8472
Practice Address - Country:US
Practice Address - Phone:928-763-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5243224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant