Provider Demographics
NPI:1174234074
Name:LUTZ, MICHELLE (DPT, OCS)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LUTZ
Suffix:
Gender:F
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 8TH AVE NE STE 320
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-5436
Mailing Address - Country:US
Mailing Address - Phone:425-313-3055
Mailing Address - Fax:425-313-3051
Practice Address - Street 1:510 8TH AVE NE STE 340
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-5449
Practice Address - Country:US
Practice Address - Phone:425-313-3055
Practice Address - Fax:425-313-3051
Is Sole Proprietor?:No
Enumeration Date:2022-12-12
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
P17682225100000X
NCP17685225100000X
WACP017064T225100000X
WAPT615138562251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2233363Medicaid