Provider Demographics
NPI:1699150318
Name:LUTZ, SHAENA (COTA/L)
Entity type:Individual
Prefix:
First Name:SHAENA
Middle Name:
Last Name:LUTZ
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1889 WEST QUEEN CREEK ROAD
Mailing Address - Street 2:#2062
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248
Mailing Address - Country:US
Mailing Address - Phone:602-410-3062
Mailing Address - Fax:
Practice Address - Street 1:1889 W QUEEN CREEK RD
Practice Address - Street 2:#2062
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-3079
Practice Address - Country:US
Practice Address - Phone:602-410-3062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6216174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ6216OtherOCCUPATIONAL THERAPY ASSISTANT