Provider Demographics
NPI:1356922009
Name:LUTZ, TANYA SUE (CADC-II)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:SUE
Last Name:LUTZ
Suffix:
Gender:F
Credentials:CADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1638 COCONUT LN
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-1501
Mailing Address - Country:US
Mailing Address - Phone:619-540-0933
Mailing Address - Fax:
Practice Address - Street 1:1260 MORENA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3850
Practice Address - Country:US
Practice Address - Phone:619-398-0355
Practice Address - Fax:619-398-0350
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA020500815101YA0400X, 171M00000X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health