Provider Demographics
NPI:1912553058
Name:TUSTIN, CAROLEE JESSICA (LICSW)
Entity Type:Individual
Prefix:
First Name:CAROLEE
Middle Name:JESSICA
Last Name:TUSTIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 SMYTH RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-7007
Mailing Address - Country:US
Mailing Address - Phone:603-624-4366
Mailing Address - Fax:603-629-3244
Practice Address - Street 1:718 SMYTH RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-7007
Practice Address - Country:US
Practice Address - Phone:603-624-4366
Practice Address - Fax:603-629-3244
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH23301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical