Provider Demographics
NPI:1902100993
Name:LUTZ, PAULA (MPT)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:LUTZ
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:PAULA
Other - Middle Name:
Other - Last Name:WATFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:2202 LAPORTE AVE
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-5936
Practice Address - Country:US
Practice Address - Phone:219-462-7577
Practice Address - Fax:219-462-7579
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010430A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000700991OtherANTHEM
IN201006510Medicaid
INM400035912Medicare PIN
IN000000700991OtherANTHEM