Provider Demographics
NPI:1447242029
Name:GUSTAFSON, CYNTHIA (RPT)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:SAUGUS
Mailing Address - State:MA
Mailing Address - Zip Code:01906-2342
Mailing Address - Country:US
Mailing Address - Phone:781-231-2292
Mailing Address - Fax:781-231-2292
Practice Address - Street 1:315 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-2342
Practice Address - Country:US
Practice Address - Phone:781-231-2292
Practice Address - Fax:781-231-2292
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3705225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY65881OtherBLUE CROSS
MA705278OtherTUFTS HEALTH PLAN
MA6400066OtherUNITED HEALTHCARE
MA0336742Medicaid
MA0336742Medicaid