Provider Demographics
NPI:1407916216
Name:GUSTAFSON, SCOTT ALLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALLEN
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 HATHORN RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-4213
Mailing Address - Country:US
Mailing Address - Phone:662-915-5272
Mailing Address - Fax:
Practice Address - Street 1:551 HATHORN RD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-4213
Practice Address - Country:US
Practice Address - Phone:662-915-5272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH907103TC0700X
MEPS1054103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH06Y001129NH01OtherBLUE CROSS BLUE SHIELD
NH201279090 01OtherHARVARD PILGRIM
NH30424636Medicaid
NH06Y001129NH01OtherBLUE CROSS BLUE SHIELD