Provider Demographics
NPI:1841651510
Name:LUTZ, ELLEN
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:LUTZ
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:PO BOX 2245
Mailing Address - Street 2:
Mailing Address - City:AQUEBOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11931-2245
Mailing Address - Country:US
Mailing Address - Phone:631-722-3298
Mailing Address - Fax:
Practice Address - Street 1:355 TUTHILLS LANE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2245
Practice Address - Country:US
Practice Address - Phone:631-722-3298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009991-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist