Provider Demographics
NPI:1033507967
Name:GUSTAFSSON, MARY GRACE CRUZ
Entity Type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:CRUZ
Last Name:GUSTAFSSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY GRACE
Other - Middle Name:
Other - Last Name:CRUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21520 BURBANK BLVD APT 102
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-7052
Mailing Address - Country:US
Mailing Address - Phone:818-405-3646
Mailing Address - Fax:
Practice Address - Street 1:21520 BURBANK BLVD APT 102
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-7052
Practice Address - Country:US
Practice Address - Phone:818-405-3646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-30
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13096225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist