Provider Demographics
NPI:1174702922
Name:GUSTAFIK, MARY (LPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GUSTAFIK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E ANTON AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-3779
Mailing Address - Country:US
Mailing Address - Phone:208-667-6095
Mailing Address - Fax:208-667-6173
Practice Address - Street 1:312 S FIRST AVE LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1202
Practice Address - Country:US
Practice Address - Phone:208-263-7727
Practice Address - Fax:208-263-7728
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3849101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health