Provider Demographics
NPI:1134351943
Name:LUSTER, KATHLEEN G
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:G
Last Name:LUSTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 FOLK ART CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-8488
Mailing Address - Country:US
Mailing Address - Phone:636-240-9826
Mailing Address - Fax:
Practice Address - Street 1:15 FOLK ART CT
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-8488
Practice Address - Country:US
Practice Address - Phone:636-240-9826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111928235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist