Provider Demographics
NPI:1407280456
Name:GUSTAFSON, TANYA L (LAMFT)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:L
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 OLD 41 HWY NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4420
Mailing Address - Country:US
Mailing Address - Phone:678-468-9103
Mailing Address - Fax:520-333-2906
Practice Address - Street 1:1815 OLD 41 HWY NW
Practice Address - Street 2:SUITE 110
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4420
Practice Address - Country:US
Practice Address - Phone:678-468-9103
Practice Address - Fax:520-333-2906
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001356106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist