Provider Demographics
NPI:1619424223
Name:LUSTIG, NICOLE
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:LUSTIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-415-0299
Mailing Address - Fax:
Practice Address - Street 1:3700 W SELTICE WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-8921
Practice Address - Country:US
Practice Address - Phone:208-620-5255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist