Provider Demographics
NPI:1063280493
Name:LUSTGARTEN, SOFIA (PSYD)
Entity type:Individual
Prefix:DR
First Name:SOFIA
Middle Name:
Last Name:LUSTGARTEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11601 BISCAYNE BLVD STE 211
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33181-3151
Mailing Address - Country:US
Mailing Address - Phone:305-343-0878
Mailing Address - Fax:
Practice Address - Street 1:11601 BISCAYNE BLVD STE 211
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33181-3151
Practice Address - Country:US
Practice Address - Phone:305-343-0878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12089103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical