Healthcare Provider Details

I. General information

NPI: 1447754148
Provider Name (Legal Business Name): DEZAREE' LA' DESTINY LUSK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 05/08/2021
Certification Date: 05/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 WESTPARK DR STE 118
HOUSTON TX
77063-5502
US

IV. Provider business mailing address

905 MACAW WAY
DESOTO TX
75115-7210
US

V. Phone/Fax

Practice location:
  • Phone: 469-499-6200
  • Fax:
Mailing address:
  • Phone: 469-499-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number62594
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number1449535
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: