Provider Demographics
NPI:1083237960
Name:STRAIGHT, DUSTIN THOMAS (MS, LAC)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:THOMAS
Last Name:STRAIGHT
Suffix:
Gender:M
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1084
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631-1084
Mailing Address - Country:US
Mailing Address - Phone:480-232-5217
Mailing Address - Fax:
Practice Address - Street 1:2205 CORDILLERA WAY
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-6290
Practice Address - Country:US
Practice Address - Phone:480-232-5217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0001463101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty