Provider Demographics
NPI:1932204625
Name:LUSK, REBECCA KOTLOWSKI (PSYD, ABPP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:KOTLOWSKI
Last Name:LUSK
Suffix:
Gender:F
Credentials:PSYD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 FULLER RD
Mailing Address - Street 2:MENTAL HEALTH CLINIC
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-2303
Mailing Address - Country:US
Mailing Address - Phone:734-769-7100
Mailing Address - Fax:734-845-3235
Practice Address - Street 1:2215 FULLER RD
Practice Address - Street 2:MENTAL HEALTH CLINIC
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2303
Practice Address - Country:US
Practice Address - Phone:734-769-7100
Practice Address - Fax:734-845-3235
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012055174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N15720Medicare ID - Type Unspecified