Provider Demographics
NPI:1477197929
Name:LUSTGARTEN, SAMUEL DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:DAVID
Last Name:LUSTGARTEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 N BLACKHAWK AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3357
Mailing Address - Country:US
Mailing Address - Phone:720-260-4362
Mailing Address - Fax:971-999-0817
Practice Address - Street 1:702 N BLACKHAWK AVE STE 205
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3357
Practice Address - Country:US
Practice Address - Phone:720-260-4362
Practice Address - Fax:971-999-0817
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-28
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3178103TC1900X
WI3717-57103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling