Healthcare Provider Details

I. General information

NPI: 1306562897
Provider Name (Legal Business Name): ERIC JAMES LAUTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 10/17/2022
Certification Date: 10/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 LENNON LN
WALNUT CREEK CA
94598-2486
US

IV. Provider business mailing address

58 TARA RD
ORINDA CA
94563-3127
US

V. Phone/Fax

Practice location:
  • Phone: 925-932-7791
  • Fax:
Mailing address:
  • Phone: 141-582-8347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCADDTP1484
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: