Provider Demographics
NPI:1558721506
Name:LUSK, BETHANY (RD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:LUSK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2967
Mailing Address - Country:US
Mailing Address - Phone:508-588-6700
Mailing Address - Fax:508-584-3010
Practice Address - Street 1:189 QUINCY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2967
Practice Address - Country:US
Practice Address - Phone:508-588-6700
Practice Address - Fax:508-584-3010
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA133VN1006X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic