Provider Demographics
NPI:1689254203
Name:SUSTAD, KEVIN
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:SUSTAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2598 ORR ST
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-4744
Mailing Address - Country:US
Mailing Address - Phone:516-941-7504
Mailing Address - Fax:
Practice Address - Street 1:2598 ORR ST
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-4744
Practice Address - Country:US
Practice Address - Phone:516-941-7504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011247101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health