Provider Demographics
NPI:1386757383
Name:LUSTER, STACEY L (PT)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:L
Last Name:LUSTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:L
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2120 N MACARTHUR BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-2221
Mailing Address - Country:US
Mailing Address - Phone:972-438-4636
Mailing Address - Fax:214-614-4496
Practice Address - Street 1:2120 N MACARTHUR BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-2221
Practice Address - Country:US
Practice Address - Phone:972-438-4636
Practice Address - Fax:214-614-4496
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1055515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00858142OtherRAILROAD MEDICARE
TX8T8068OtherBCBS OF TEXAS
TX8K6085Medicare UPIN