Provider Demographics
NPI:1427729227
Name:SAMUEL LUSTGARTEN PHD LLC
Entity type:Organization
Organization Name:SAMUEL LUSTGARTEN PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LUSTGARTEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:720-260-4362
Mailing Address - Street 1:702 N BLACKHAWK AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3357
Mailing Address - Country:US
Mailing Address - Phone:720-260-4362
Mailing Address - Fax:971-999-0817
Practice Address - Street 1:702 N BLACKHAWK AVE STE 205
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3357
Practice Address - Country:US
Practice Address - Phone:720-260-4362
Practice Address - Fax:971-999-0817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-22
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)