Provider Demographics
NPI:1902380710
Name:LUSTIG, SUSAN ANN (LPTA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ANN
Last Name:LUSTIG
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:ANN
Other - Last Name:LUSTIG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPTA
Mailing Address - Street 1:107 JUDD CT
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-4080
Mailing Address - Country:US
Mailing Address - Phone:434-258-1326
Mailing Address - Fax:
Practice Address - Street 1:189 MONICA BLVD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2213
Practice Address - Country:US
Practice Address - Phone:434-847-2860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602140225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA$$$$$$$$$OtherGENERAL INSURANCE