Provider Demographics
NPI:1508102658
Name:LUSK, RONNIE
Entity Type:Individual
Prefix:
First Name:RONNIE
Middle Name:
Last Name:LUSK
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 1:2145 NICE AVE
Mailing Address - Street 2:
Mailing Address - City:MENTONE
Mailing Address - State:CA
Mailing Address - Zip Code:92359-9643
Mailing Address - Country:US
Mailing Address - Phone:909-810-1481
Mailing Address - Fax:
Practice Address - Street 1:2145 NICE AVE
Practice Address - Street 2:
Practice Address - City:MENTONE
Practice Address - State:CA
Practice Address - Zip Code:92359-9643
Practice Address - Country:US
Practice Address - Phone:909-810-1481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-18
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA113838106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator