Healthcare Provider Details

I. General information

NPI: 1528101706
Provider Name (Legal Business Name): STACEY NICHOLE LUSK MT-BC, DT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40W310 LAFOX RD SUITE 1A
ST CHARLES IL
60175-6588
US

IV. Provider business mailing address

746 N GLENWOOD PL
AURORA IL
60506-1908
US

V. Phone/Fax

Practice location:
  • Phone: 630-444-0077
  • Fax:
Mailing address:
  • Phone: 630-546-0380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: