MEDICARE: MR. BLAKE JOHN LUTZ LCSW

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	1041C0700X	Clinical Social Worker	C007651	NC
2	1041C0700X	Clinical Social Worker	44SC05489300	NJ

General Provider Information

NPI Number	:	1407374911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BLAKE JOHN LUTZ LCSW

Provider Business Mailing Address
First Line	:	2925 LANDON RIDGE DR
Second Line	:
City	:	NEW HILL
State	:	NC
Zip	:	27562-9305
Country	:	US
Telephone Number	:	919-593-5500
Fax Number	:

Provider Business Practice Location Address
First Line	:	2925 LANDON RIDGE DR
Second Line	:
City	:	NEW HILL
State	:	NC
Zip	:	27562-2756
Country	:	US
Telephone Number	:	919-593-5500
Fax Number	:

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

Provider Enumeration Date	:	09/05/2017
Last Update Date	:	09/05/2017

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