Provider Demographics
NPI:1164926648
Name:GUSTIN, EMILIE
Entity Type:Individual
Prefix:
First Name:EMILIE
Middle Name:
Last Name:GUSTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILIE
Other - Middle Name:
Other - Last Name:MOONSHOWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1605 S WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-2194
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1605 S WAYNE ST
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-2194
Practice Address - Country:US
Practice Address - Phone:260-243-4720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator