Provider Demographics
NPI:1558987941
Name:RUSTAM, KEVIN (PSYD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:RUSTAM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-7827
Mailing Address - Country:US
Mailing Address - Phone:212-720-4540
Mailing Address - Fax:
Practice Address - Street 1:253 SOUTH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7827
Practice Address - Country:US
Practice Address - Phone:646-740-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024650103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty