Provider Demographics
NPI:1710011978
Name:LUSTIG, AMANDA KAY (BS)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:KAY
Last Name:LUSTIG
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N12697 350TH ST
Mailing Address - Street 2:
Mailing Address - City:BOYCEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54725-9459
Mailing Address - Country:US
Mailing Address - Phone:715-949-1630
Mailing Address - Fax:
Practice Address - Street 1:808 MAIN ST E
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2735
Practice Address - Country:US
Practice Address - Phone:715-232-1116
Practice Address - Fax:715-232-5987
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIL232-0117-8560-09171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator