Provider Demographics
NPI:1164277570
Name:GUSTIN, CARMEN A (SAC-IT, IDP-AT)
Entity Type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:A
Last Name:GUSTIN
Suffix:
Gender:F
Credentials:SAC-IT, IDP-AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-2405
Mailing Address - Country:US
Mailing Address - Phone:262-638-6612
Mailing Address - Fax:
Practice Address - Street 1:1717 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-2405
Practice Address - Country:US
Practice Address - Phone:262-638-6612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20545-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)