Provider Demographics
NPI:1437271350
Name:GUSTAFSON, JANINE L (MFT)
Entity Type:Individual
Prefix:
First Name:JANINE
Middle Name:L
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 RIMPAU AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-5723
Mailing Address - Country:US
Mailing Address - Phone:951-277-7726
Mailing Address - Fax:
Practice Address - Street 1:710 RIMPAU AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-5723
Practice Address - Country:US
Practice Address - Phone:951-277-7726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30417106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist