Provider Demographics
NPI:1770078412
Name:LUTZ, WHITNEY LANE (COTA)
Entity type:Individual
Prefix:
First Name:WHITNEY
Middle Name:LANE
Last Name:LUTZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CLEAVELAND ST APT B
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2110
Mailing Address - Country:US
Mailing Address - Phone:812-340-9994
Mailing Address - Fax:
Practice Address - Street 1:1031 E KNOLLWOOD CIR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-4561
Practice Address - Country:US
Practice Address - Phone:812-340-9994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002661A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN22738Medicaid