Provider Demographics
NPI:1316043128
Name:LUTZ, SHANNON COURTNEY (LPA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:COURTNEY
Last Name:LUTZ
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 MOCKINGBIRD LN
Mailing Address - Street 2:SUITE 515
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3236
Mailing Address - Country:US
Mailing Address - Phone:704-999-4191
Mailing Address - Fax:980-949-8180
Practice Address - Street 1:1515 MOCKINGBIRD LN
Practice Address - Street 2:SUITE 515
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3236
Practice Address - Country:US
Practice Address - Phone:704-999-4191
Practice Address - Fax:980-949-8180
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2532103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107208Medicaid