Provider Demographics
NPI:1457768871
Name:LAMPORT, DUSTIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:
Last Name:LAMPORT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9047 EXECUTIVE PARK DR STE 210
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4625
Mailing Address - Country:US
Mailing Address - Phone:865-983-1899
Mailing Address - Fax:865-297-4240
Practice Address - Street 1:9047 EXECUTIVE PARK DR STE 210
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4625
Practice Address - Country:US
Practice Address - Phone:865-983-1899
Practice Address - Fax:658-297-4240
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP3339103T00000X, 103TC0700X
MI6301015949390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ025600Medicaid