Provider Demographics
NPI:1215087671
Name:LUSTIBER, LAURIE ANN (MS, CCC-SP)
Entity type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:ANN
Last Name:LUSTIBER
Suffix:
Gender:F
Credentials:MS, CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 MEADOWS END RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-1741
Mailing Address - Country:US
Mailing Address - Phone:203-261-6582
Mailing Address - Fax:203-268-1084
Practice Address - Street 1:182 MEADOWS END RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-1741
Practice Address - Country:US
Practice Address - Phone:203-261-6582
Practice Address - Fax:203-268-1084
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001987235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT660001987CT01OtherANTHEM BC-BS