Provider Demographics
NPI:1023843653
Name:LUSTIG, JONAH (PSYD)
Entity type:Individual
Prefix:DR
First Name:JONAH
Middle Name:
Last Name:LUSTIG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JONAH
Other - Middle Name:MATTHEW
Other - Last Name:LUSTIG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:1501 SAN PEDRO DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-5153
Mailing Address - Country:US
Mailing Address - Phone:505-265-1711
Mailing Address - Fax:
Practice Address - Street 1:1501 SAN PEDRO DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5153
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPSY-2024-0065103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical