Provider Demographics
NPI:1164631123
Name:GUSDAL, PAMELA JUNE (MT-BC)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:JUNE
Last Name:GUSDAL
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9005 W 34TH ST
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-3703
Mailing Address - Country:US
Mailing Address - Phone:612-423-6523
Mailing Address - Fax:
Practice Address - Street 1:3630 PHILLIPS PKWY
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-3792
Practice Address - Country:US
Practice Address - Phone:952-939-1606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN03886225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist