Provider Demographics
NPI:1073937603
Name:GUSTUS, MINDY (BSW, LAC)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:GUSTUS
Suffix:
Gender:F
Credentials:BSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 N MILLWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-5850
Mailing Address - Country:US
Mailing Address - Phone:316-265-6011
Mailing Address - Fax:316-265-4022
Practice Address - Street 1:122 N MILLWOOD ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-5850
Practice Address - Country:US
Practice Address - Phone:316-265-6011
Practice Address - Fax:316-265-4022
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLAC 476101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)