Provider Demographics
NPI:1427413798
Name:GUSTAFSON, ROBERTA (LMSW)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 N 15TH AVE APT 9A
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4042
Mailing Address - Country:US
Mailing Address - Phone:208-957-1136
Mailing Address - Fax:
Practice Address - Street 1:1501 BENCH RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2443
Practice Address - Country:US
Practice Address - Phone:208-242-3044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-33483104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker