Provider Demographics
NPI:1740907237
Name:LUSTY, DOROTHE
Entity type:Individual
Prefix:
First Name:DOROTHE
Middle Name:
Last Name:LUSTY
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 1:11301 CARMEL COMMONS BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-5305
Mailing Address - Country:US
Mailing Address - Phone:949-600-3400
Mailing Address - Fax:
Practice Address - Street 1:11301 CARMEL COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-5318
Practice Address - Country:US
Practice Address - Phone:949-600-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty