Basic Information
| Provider Information | |||||||||
| NPI: | 1144626144 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUTZ | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | JEANNE | ||||||||
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| Credential: | LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 E EARLL DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025995404 | ||||||||
| FaxNumber: | 6025995704 | ||||||||
| Practice Location | |||||||||
| Address1: | 2505 W BERYL AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850211641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025995465 | ||||||||
| FaxNumber: | 6022622111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2014 | ||||||||
| LastUpdateDate: | 11/18/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LAC-13394 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.