Provider Demographics
NPI:1184134314
Name:RUSTAD, COLLEEN (PHD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:RUSTAD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3516 ROSS AVE
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98332-2105
Mailing Address - Country:US
Mailing Address - Phone:602-509-5660
Mailing Address - Fax:
Practice Address - Street 1:3224 6TH AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-5902
Practice Address - Country:US
Practice Address - Phone:253-579-8278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60820191103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical