Provider Demographics
NPI:1730283367
Name:HUSTAD, DEBRA LYNN (MASTER OF SCIENCE LC)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:LYNN
Last Name:HUSTAD
Suffix:
Gender:F
Credentials:MASTER OF SCIENCE LC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 ODANA COURT
Mailing Address - Street 2:SUITE 203 UPLANDS COUNSELING ASSOCIATES
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719
Mailing Address - Country:US
Mailing Address - Phone:608-274-5181
Mailing Address - Fax:608-274-2848
Practice Address - Street 1:9 ODANA COURT
Practice Address - Street 2:SUITE 203
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719
Practice Address - Country:US
Practice Address - Phone:608-274-5181
Practice Address - Fax:608-274-2848
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2810123LCSW101YM0800X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1011471OtherPHYSICIANS PLUS HMO
WI39597500Medicaid