MEDICARE: DR. TERRI S LUSTICK PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	PS008431L	PA

General Provider Information

NPI Number	:	1649348335
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRI S LUSTICK PH.D.

Provider Business Mailing Address
First Line	:	11 BALA AVE
Second Line	:
City	:	BALA CYNWYD
State	:	PA
Zip	:	19004-3201
Country	:	US
Telephone Number	:	610-668-2290
Fax Number	:

Provider Business Practice Location Address
First Line	:	11 BALA AVE
Second Line	:
City	:	BALA CYNWYD
State	:	PA
Zip	:	19004-3201
Country	:	US
Telephone Number	:	610-668-2290
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	07/08/2007

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