Healthcare Provider Details

I. General information

NPI: 1902044688
Provider Name (Legal Business Name): ROBERT NEIL LUSK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 02/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 BEECH ST. BLDG. 7
NORMAL IL
61761
US

IV. Provider business mailing address

612 OGLESBY AVE.
NORMAL IL
61761
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-1770
  • Fax: 309-454-9257
Mailing address:
  • Phone: 309-454-1770
  • Fax: 309-454-9257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-004615
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: