1891931895 NPI number — SHANNON RAE LUTZ LCSW

Table of content: MRS. CARLA RENEE BONDS (NPI 1275050866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891931895 NPI number — SHANNON RAE LUTZ LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUTZ
Provider First Name:
SHANNON
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891931895
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15735 W US HIGHWAY 63
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYWARD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54843-6475
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-934-0710
Provider Business Mailing Address Fax Number:
715-598-4881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 5TH AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HURLEY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54534-1208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
153-291-2887
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801090552 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 10176 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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