Provider Demographics
NPI:1760431456
Name:LUSTBERG, RICHARD SCOTT (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:SCOTT
Last Name:LUSTBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-5740
Mailing Address - Country:US
Mailing Address - Phone:516-678-9155
Mailing Address - Fax:
Practice Address - Street 1:80 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-5740
Practice Address - Country:US
Practice Address - Phone:516-678-9155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009885-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV54412Medicare ID - Type Unspecified
NYV54411Medicare ID - Type Unspecified