Provider Demographics
NPI:1306478938
Name:LUSTIG, BETTY E (MED/LMHC)
Entity type:Individual
Prefix:MS
First Name:BETTY
Middle Name:E
Last Name:LUSTIG
Suffix:
Gender:F
Credentials:MED/LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4280 REDTAIL HAWK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-8116
Mailing Address - Country:US
Mailing Address - Phone:786-258-2819
Mailing Address - Fax:
Practice Address - Street 1:4280 REDTAIL HAWK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8116
Practice Address - Country:US
Practice Address - Phone:786-258-2819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0000606101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health