Provider Demographics
NPI:1629159355
Name:HUSTAD, MYRON IRVING (MSW LCSW ACSW AAMFT)
Entity Type:Individual
Prefix:MR
First Name:MYRON
Middle Name:IRVING
Last Name:HUSTAD
Suffix:
Gender:M
Credentials:MSW LCSW ACSW AAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8705 GLENCOE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-774-6158
Mailing Address - Fax:
Practice Address - Street 1:5000 WEST NATIONAL AVENUE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295
Practice Address - Country:US
Practice Address - Phone:414-384-2000
Practice Address - Fax:414-382-5295
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22461231041C0700X
WI241124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist