Provider Demographics
NPI:1336111475
Name:GUSTAVSON, DARLENE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DARLENE
Middle Name:
Last Name:GUSTAVSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 ELM ST
Mailing Address - Street 2:SUITE 515
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-2130
Mailing Address - Country:US
Mailing Address - Phone:603-703-2900
Mailing Address - Fax:
Practice Address - Street 1:814 ELM ST
Practice Address - Street 2:SUITE 515
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-2130
Practice Address - Country:US
Practice Address - Phone:603-703-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6867103TC0700X
NH1115103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical