Provider Demographics
NPI:1720853377
Name:LUSTOSA, KAYLA
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:LUSTOSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 PR SMITH BLVD
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-8023
Mailing Address - Country:US
Mailing Address - Phone:404-574-0359
Mailing Address - Fax:
Practice Address - Street 1:175 GWINNETT DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8444
Practice Address - Country:US
Practice Address - Phone:678-209-2394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC009402101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health