Provider Demographics
NPI:1164145413
Name:GUSTAFSON, AMBERLEE (DTCM, LAC)
Entity Type:Individual
Prefix:MISS
First Name:AMBERLEE
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:DTCM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:981 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-4320
Mailing Address - Country:US
Mailing Address - Phone:707-616-8215
Mailing Address - Fax:
Practice Address - Street 1:981 35TH AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-4320
Practice Address - Country:US
Practice Address - Phone:707-616-8215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19212171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist