MEDICARE: SHANNON COURTNEY LUTZ LPA

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	103T00000X	Psychologist	2532	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316043128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON COURTNEY LUTZ LPA

Provider Business Mailing Address
First Line	:	1515 MOCKINGBIRD LN
Second Line	:	SUITE 515
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3236
Country	:	US
Telephone Number	:	704-999-4191
Fax Number	:	980-949-8180

Provider Business Practice Location Address
First Line	:	1515 MOCKINGBIRD LN
Second Line	:	SUITE 515
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3236
Country	:	US
Telephone Number	:	704-999-4191
Fax Number	:	980-949-8180

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

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	01/11/2013

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