Provider Demographics
NPI:1962063511
Name:LUTZ, ADAM
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:LUTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 HARRISON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-1300
Mailing Address - Country:US
Mailing Address - Phone:651-460-1173
Mailing Address - Fax:
Practice Address - Street 1:515 HARRISON AVE STE A
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-1300
Practice Address - Country:US
Practice Address - Phone:360-870-2473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11533225100000X
WAPT61113239225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist