Provider Demographics
NPI:1104145143
Name:TUSTIN, LARRY CARL (BA, CADC)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:CARL
Last Name:TUSTIN
Suffix:
Gender:M
Credentials:BA, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 504
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0504
Mailing Address - Country:US
Mailing Address - Phone:918-649-5035
Mailing Address - Fax:
Practice Address - Street 1:501 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4215
Practice Address - Country:US
Practice Address - Phone:918-649-5035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)