Provider Demographics
NPI:1114379765
Name:GUSTIN, HALLIE L (LISW-S)
Entity Type:Individual
Prefix:MS
First Name:HALLIE
Middle Name:L
Last Name:GUSTIN
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2508
Mailing Address - Country:US
Mailing Address - Phone:216-361-4400
Mailing Address - Fax:216-361-2340
Practice Address - Street 1:14201 SOUTHINGTON RD
Practice Address - Street 2:
Practice Address - City:SHAKER HTS
Practice Address - State:OH
Practice Address - Zip Code:44120-2703
Practice Address - Country:US
Practice Address - Phone:216-751-8453
Practice Address - Fax:216-361-2340
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0009098-SUPV1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool