Provider Demographics
NPI:1740838697
Name:LUSTIG, JULIE LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:JULIE
Middle Name:LYNN
Last Name:LUSTIG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4807
Mailing Address - Country:US
Mailing Address - Phone:650-289-9100
Mailing Address - Fax:
Practice Address - Street 1:843 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4807
Practice Address - Country:US
Practice Address - Phone:650-289-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15670103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical