Provider Demographics
NPI:1528101706
Name:LUSK, STACEY NICHOLE (MT-BC, DT)
Entity type:Individual
Prefix:MISS
First Name:STACEY
Middle Name:NICHOLE
Last Name:LUSK
Suffix:
Gender:F
Credentials:MT-BC, DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:746 N GLENWOOD PL
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-1908
Mailing Address - Country:US
Mailing Address - Phone:630-546-0380
Mailing Address - Fax:
Practice Address - Street 1:40W310 LAFOX RD
Practice Address - Street 2:SUITE 1A
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-6588
Practice Address - Country:US
Practice Address - Phone:630-444-0077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist