Provider Demographics
NPI:1619424223
Name:LUSTIG, NICOLE
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:LUSTIG
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 1:4800 SAND POINT WAY NE, MS OA.5.154
Mailing Address - Street 2:SEATTLE CHILDREN'S HOSPITAL
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105
Mailing Address - Country:US
Mailing Address - Phone:206-987-2164
Mailing Address - Fax:
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:SEATTLE CHILDREN'S HOSPITAL
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105
Practice Address - Country:US
Practice Address - Phone:206-987-2164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst