Provider Demographics
NPI:1164993317
Name:LUSTGARTEN, ELAINE KATE (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:KATE
Last Name:LUSTGARTEN
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 E 500 N
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-8333
Mailing Address - Country:US
Mailing Address - Phone:219-669-8318
Mailing Address - Fax:
Practice Address - Street 1:9042 COLUMBIA AVE STE B
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2928
Practice Address - Country:US
Practice Address - Phone:219-836-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20000339702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer