Provider Demographics
NPI:1598981904
Name:LUSTIG, LAURA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:LUSTIG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 JOHN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890-1436
Mailing Address - Country:US
Mailing Address - Phone:203-307-3030
Mailing Address - Fax:203-255-7486
Practice Address - Street 1:49 JOHN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890-1436
Practice Address - Country:US
Practice Address - Phone:203-307-3030
Practice Address - Fax:203-255-7486
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT 001785103TC0700X
CTCT 000015106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist