Provider Demographics
NPI:1649821372
Name:TUSTIN, EMMA LEIGH (BS, RBT)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:LEIGH
Last Name:TUSTIN
Suffix:
Gender:F
Credentials:BS, RBT
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:LEIGH
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, RBT
Mailing Address - Street 1:9038 CROSS PARK DR STE 105
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4720
Mailing Address - Country:US
Mailing Address - Phone:865-394-6612
Mailing Address - Fax:865-315-7014
Practice Address - Street 1:9038 CROSS PARK DR STE 105
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4720
Practice Address - Country:US
Practice Address - Phone:865-394-6612
Practice Address - Fax:865-315-7014
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYRBT-19-91809106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYRBT-19-91809OtherRBT CERTIFICATE