Provider Demographics
NPI:1730692336
Name:GUSTAVSON, KRISTY
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:GUSTAVSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3785 BAY RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2433
Mailing Address - Country:US
Mailing Address - Phone:989-791-2455
Mailing Address - Fax:989-791-1392
Practice Address - Street 1:4046 HESS AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-4261
Practice Address - Country:US
Practice Address - Phone:989-753-7781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017237101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty