Provider Demographics
NPI:1912125352
Name:LUTZ, MICHAEL GORDON (OTRL)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GORDON
Last Name:LUTZ
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 MULVIHILL AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374
Mailing Address - Country:US
Mailing Address - Phone:909-792-0015
Mailing Address - Fax:909-792-0015
Practice Address - Street 1:303 MULVIHILL AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374
Practice Address - Country:US
Practice Address - Phone:909-792-0015
Practice Address - Fax:909-792-0015
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT4561225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist