Provider Demographics
NPI:1992160618
Name:RUSTULKA, SCOTT (MS, QASP)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:RUSTULKA
Suffix:
Gender:M
Credentials:MS, QASP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11665 AVENA PL
Mailing Address - Street 2:STE 204
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2421
Mailing Address - Country:US
Mailing Address - Phone:760-349-4200
Mailing Address - Fax:760-349-4200
Practice Address - Street 1:11665 AVENA PL
Practice Address - Street 2:STE 204
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2421
Practice Address - Country:US
Practice Address - Phone:760-349-4200
Practice Address - Fax:760-349-4200
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQASPOtherQASP