Provider Demographics
NPI:1114997319
Name:GUSTAFSON, MARSHA A (LPC)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:A
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 S 600 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2708
Mailing Address - Country:US
Mailing Address - Phone:801-538-2057
Mailing Address - Fax:801-596-2515
Practice Address - Street 1:443 S 600 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2708
Practice Address - Country:US
Practice Address - Phone:801-538-2057
Practice Address - Fax:801-596-2515
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5227281-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107032312101Medicare UPIN