Provider Demographics
NPI:1700989837
Name:LUSTIG, LINDA (MS ART THERAPY)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:
Last Name:LUSTIG
Suffix:
Gender:F
Credentials:MS ART THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10229 W GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214
Mailing Address - Country:US
Mailing Address - Phone:414-453-6330
Mailing Address - Fax:
Practice Address - Street 1:10229 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214
Practice Address - Country:US
Practice Address - Phone:414-453-6330
Practice Address - Fax:414-453-6523
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2531125104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39692400Medicaid