Provider Demographics
NPI:1366086407
Name:LUSTGARTEN, NOA (PT)
Entity type:Individual
Prefix:
First Name:NOA
Middle Name:
Last Name:LUSTGARTEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 BEACON ST STE 209
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-3202
Mailing Address - Country:US
Mailing Address - Phone:857-990-6111
Mailing Address - Fax:
Practice Address - Street 1:1330 BEACON ST STE 209
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3202
Practice Address - Country:US
Practice Address - Phone:857-990-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21022208100000X, 2081P2900X, 2081S0010X, 208VP0000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine