Basic Information
Provider Information | |||||||||
NPI: | 1619636586 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LUTZA | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: | RACHEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S., BCBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LUTZA | ||||||||
OtherFirstName: | SAMANTHA | ||||||||
OtherMiddleName: | RACHEL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | BCBA | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 28245 AVENUE CROCKER STE 220 | ||||||||
Address2: |   | ||||||||
City: | VALENCIA | ||||||||
State: | CA | ||||||||
PostalCode: | 913551201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6612547086 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 28245 AVENUE CROCKER STE 220 | ||||||||
Address2: |   | ||||||||
City: | VALENCIA | ||||||||
State: | CA | ||||||||
PostalCode: | 913551201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6612547086 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/08/2021 | ||||||||
LastUpdateDate: | 11/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 1-21-55339 | CA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.