Provider Demographics
NPI:1659967776
Name:LUTTRELL, TANYA RENEE
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:RENEE
Last Name:LUTTRELL
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 1:8745 FOLSOM BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-3712
Mailing Address - Country:US
Mailing Address - Phone:916-206-7269
Mailing Address - Fax:
Practice Address - Street 1:8745 FOLSOM BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-3712
Practice Address - Country:US
Practice Address - Phone:916-206-7269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-13
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC123123106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist