Provider Demographics
NPI:1063444743
Name:GUSTAVSEN, KERI LYN (PT)
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:LYN
Last Name:GUSTAVSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 372
Mailing Address - Street 2:
Mailing Address - City:ARGYLE
Mailing Address - State:TX
Mailing Address - Zip Code:76226-0372
Mailing Address - Country:US
Mailing Address - Phone:940-464-0055
Mailing Address - Fax:940-464-7755
Practice Address - Street 1:100 COUNTRY CLUB RD STE 120
Practice Address - Street 2:
Practice Address - City:ARGYLE
Practice Address - State:TX
Practice Address - Zip Code:76226-2358
Practice Address - Country:US
Practice Address - Phone:940-464-0055
Practice Address - Fax:940-464-7755
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1161526225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00852663OtherMEDICARE RAILROAD
TX825T48OtherBCBS
P00852663OtherMEDICARE RAILROAD