Provider Demographics
NPI:1164648424
Name:LUSTIG, VINCENT (PHD, CCC-A)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:LUSTIG
Suffix:
Gender:M
Credentials:PHD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5006 RENARD ST
Mailing Address - Street 2:
Mailing Address - City:SISSONVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25320-9623
Mailing Address - Country:US
Mailing Address - Phone:304-988-1760
Mailing Address - Fax:
Practice Address - Street 1:2205 WASHINGTON ST E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-2218
Practice Address - Country:US
Practice Address - Phone:304-345-8522
Practice Address - Fax:304-344-5305
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVA0063231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1022588OtherWORKER'S COMP
WV0160699000Medicaid