Provider Demographics
NPI:1942666862
Name:GUSTAVSON, PATRICIA (LMSW)
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:
Last Name:GUSTAVSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3345
Mailing Address - Country:US
Mailing Address - Phone:888-500-2067
Mailing Address - Fax:
Practice Address - Street 1:700 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3345
Practice Address - Country:US
Practice Address - Phone:718-299-3045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096648104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355940Medicaid
NYWVE061OtherMEDICARE #
NY1285628552OtherAGENCIES