Healthcare Provider Details

I. General information

NPI: 1780461319
Provider Name (Legal Business Name): AUTUM M LUSTFIELD LMAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N LORRAINE ST STE 202
HUTCHINSON KS
67501-5600
US

IV. Provider business mailing address

1600 N LORRAINE ST STE 202
HUTCHINSON KS
67501-5600
US

V. Phone/Fax

Practice location:
  • Phone: 620-663-7595
  • Fax: 620-513-5098
Mailing address:
  • Phone: 620-663-7595
  • Fax: 620-513-5098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number01229-T
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number04483
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: