MEDICARE: MR. JOSHUA ANTHONY LUTZ ED,S, NCSP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	SS795	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11997743	OTHER	FL	CAQH

General Provider Information

NPI Number	:	1114158227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSHUA ANTHONY LUTZ ED,S, NCSP

Provider Business Mailing Address
First Line	:	91 BAY BRIDGE DR
Second Line	:	SUITE D
City	:	GULF BREEZE
State	:	FL
Zip	:	32561-4468
Country	:	US
Telephone Number	:	866-960-8806
Fax Number	:	866-960-8806

Provider Business Practice Location Address
First Line	:	91 BAY BRIDGE DR
Second Line	:	SUITE D
City	:	GULF BREEZE
State	:	FL
Zip	:	32561-4468
Country	:	US
Telephone Number	:	866-960-8806
Fax Number	:	866-960-8806

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2009
Last Update Date	:	12/03/2009

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