Provider Demographics
NPI:1376378620
Name:LUST, KAILIN LYNN (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:KAILIN
Middle Name:LYNN
Last Name:LUST
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 LAKEMONT DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-7951
Mailing Address - Country:US
Mailing Address - Phone:319-321-5076
Mailing Address - Fax:
Practice Address - Street 1:31 LAKEMONT DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304-7951
Practice Address - Country:US
Practice Address - Phone:319-321-5076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024017879225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist