Healthcare Provider Details

I. General information

NPI: 1891931895
Provider Name (Legal Business Name): SHANNON RAE LUTZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2008
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 5TH AVE N
HURLEY WI
54534-1208
US

IV. Provider business mailing address

15735 W US HIGHWAY 63
HAYWARD WI
54843-6475
US

V. Phone/Fax

Practice location:
  • Phone: 153-291-2887
  • Fax:
Mailing address:
  • Phone: 715-934-0710
  • Fax: 715-598-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801090552
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10176
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: