Provider Demographics
NPI:1386371151
Name:LUSTEK, LAUREN C (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:C
Last Name:LUSTEK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3725 TRIBECA DR APT 302
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-1416
Mailing Address - Country:US
Mailing Address - Phone:715-590-2501
Mailing Address - Fax:
Practice Address - Street 1:1321 E POPLAR ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-4807
Practice Address - Country:US
Practice Address - Phone:575-546-5951
Practice Address - Fax:575-546-5994
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSLP7695235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist