Provider Demographics
NPI:1952457079
Name:RUSTAD, ERIC M (MA, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:M
Last Name:RUSTAD
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2228 MISTLETOE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1145
Mailing Address - Country:US
Mailing Address - Phone:817-939-7307
Mailing Address - Fax:
Practice Address - Street 1:2228 MISTLETOE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1145
Practice Address - Country:US
Practice Address - Phone:817-939-7307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18992235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10048486OtherAMERIGROUP