Provider Demographics
NPI:1467586412
Name:USTICO, LORI A (BOC ABC CERTIFIED)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:A
Last Name:USTICO
Suffix:
Gender:F
Credentials:BOC ABC CERTIFIED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06018-2011
Mailing Address - Country:US
Mailing Address - Phone:860-824-7510
Mailing Address - Fax:866-686-1517
Practice Address - Street 1:170 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06018-2011
Practice Address - Country:US
Practice Address - Phone:860-824-7510
Practice Address - Fax:866-686-1517
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTD16532 BOC1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2733042OtherAETNA PROVIDER NUMBER
CT12DME0614CT01OtherBLUE CROSS PROVIDER NUMBE