Provider Demographics
NPI:1144668682
Name:PUSTEJOVSKY, CARMEN LAINE (AUD)
Entity type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:LAINE
Last Name:PUSTEJOVSKY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 POOL RD
Mailing Address - Street 2:102
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-4266
Mailing Address - Country:US
Mailing Address - Phone:817-488-1637
Mailing Address - Fax:817-488-2854
Practice Address - Street 1:2200 POOL RD
Practice Address - Street 2:102
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-4266
Practice Address - Country:US
Practice Address - Phone:817-488-1637
Practice Address - Fax:817-488-2854
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80498231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist