Provider Demographics
NPI:1407105612
Name:GUSTAFSON, THOMAS HADLEY (DPT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:HADLEY
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 N 2ND ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2259
Mailing Address - Country:US
Mailing Address - Phone:269-687-9594
Mailing Address - Fax:269-687-9543
Practice Address - Street 1:20 N 2ND ST
Practice Address - Street 2:SUITE 3
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2259
Practice Address - Country:US
Practice Address - Phone:269-687-9594
Practice Address - Fax:269-687-9543
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist