Provider Demographics
NPI:1235246125
Name:GUSTAFSON, CARL (PT)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SWEETBRIAR LN
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36067-1935
Mailing Address - Country:US
Mailing Address - Phone:334-356-1218
Mailing Address - Fax:334-356-1219
Practice Address - Street 1:1801 W 2ND ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1503
Practice Address - Country:US
Practice Address - Phone:334-356-1218
Practice Address - Fax:334-356-1219
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH2732OtherLICENSE #