Provider Demographics
NPI:1538235312
Name:LUTZ, JOHN ROMAN (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROMAN
Last Name:LUTZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 IRONWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-6118
Mailing Address - Country:US
Mailing Address - Phone:770-704-7510
Mailing Address - Fax:770-592-9095
Practice Address - Street 1:240 CREEKSTONE RDG
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3732
Practice Address - Country:US
Practice Address - Phone:770-592-9065
Practice Address - Fax:770-592-9095
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-25
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001726103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000515171CMedicaid
GA68BBCPLMedicare PIN