Provider Demographics
NPI:1386662294
Name:LUTZ, LARRY W II (MS)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:W
Last Name:LUTZ
Suffix:II
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N 3RD E
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-2733
Mailing Address - Country:US
Mailing Address - Phone:208-284-0959
Mailing Address - Fax:208-587-4269
Practice Address - Street 1:210 N 3RD E
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2733
Practice Address - Country:US
Practice Address - Phone:208-284-0959
Practice Address - Fax:208-587-4269
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-4128101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional