1437488475 NPI number — BETH M LUTZ PSYD, LP

Table of content: BETH M LUTZ PSYD, LP (NPI 1437488475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437488475 NPI number — BETH M LUTZ PSYD, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUTZ
Provider First Name:
BETH
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYD, LP
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:
1437488475
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1751 TOWER DR W STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STILLWATER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55082-7596
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-439-2059
Provider Business Mailing Address Fax Number:
888-675-8262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7616 CURRELL BLVD STE 190
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125-8202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-439-2059
Provider Business Practice Location Address Fax Number:
888-675-8262
Provider Enumeration Date:
12/22/2009

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: 103T00000X , with the licence number:  5483 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: LP5483 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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