Healthcare Provider Details

I. General information

NPI: 1164993317
Provider Name (Legal Business Name): ELAINE KATE LUSTGARTEN MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 12/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9042 COLUMBIA AVE STE B
MUNSTER IN
46321-2928
US

IV. Provider business mailing address

379 E 500 N
VALPARAISO IN
46383-8333
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-4461
  • Fax:
Mailing address:
  • Phone: 219-669-8318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000033970
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: