Healthcare Provider Details

I. General information

NPI: 1356807176
Provider Name (Legal Business Name): SUNNY ELLEN LUSK MA, LPA INDEPENDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2019
Last Update Date: 02/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 PINECROFT DR STE 250
SHENANDOAH TX
77380-3286
US

IV. Provider business mailing address

611 GLEN HAVEN DR
CONROE TX
77385-7712
US

V. Phone/Fax

Practice location:
  • Phone: 281-419-8400
  • Fax: 281-292-1972
Mailing address:
  • Phone: 281-210-4119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number36448
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: