Provider Demographics
NPI:1801451752
Name:LUTTRELL, CODY (DPT)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:LUTTRELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8305 SHOAL CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-7525
Mailing Address - Country:US
Mailing Address - Phone:512-646-2743
Mailing Address - Fax:
Practice Address - Street 1:8305 SHOAL CREEK BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-7525
Practice Address - Country:US
Practice Address - Phone:512-646-2743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1317589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1801451752Medicaid