Provider Demographics
NPI:1295925386
Name:LUSK, DELLA S (PHD)
Entity type:Individual
Prefix:DR
First Name:DELLA
Middle Name:S
Last Name:LUSK
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 1:710 N. BEAVER STREET
Mailing Address - Street 2:BLDG 4
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3139
Mailing Address - Country:US
Mailing Address - Phone:928-774-7997
Mailing Address - Fax:
Practice Address - Street 1:710 N. BEAVER STREET
Practice Address - Street 2:BLDG 4
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3139
Practice Address - Country:US
Practice Address - Phone:928-774-7997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3232103G00000X, 103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic