Provider Demographics
NPI:1235412206
Name:LUSCO, MATTIE G
Entity Type:Individual
Prefix:MS
First Name:MATTIE
Middle Name:G
Last Name:LUSCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 BEECHWOOD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-6236
Mailing Address - Country:US
Mailing Address - Phone:904-358-1211
Mailing Address - Fax:
Practice Address - Street 1:623 BEECHWOOD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-6236
Practice Address - Country:US
Practice Address - Phone:904-358-1211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL675446500Medicaid