Provider Demographics
NPI:1346451523
Name:GUSTAFSON, ANDREA L (LCSW, LMT)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:L
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LCSW, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 PUMPHOUSE RD
Mailing Address - Street 2:UNIT C
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-4041
Mailing Address - Country:US
Mailing Address - Phone:715-861-3108
Mailing Address - Fax:
Practice Address - Street 1:1808 FOLSOM ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-2579
Practice Address - Country:US
Practice Address - Phone:715-404-9031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-27
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7649-1231041C0700X
WI4982-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist