Provider Demographics
NPI:1457007817
Name:GUSTAFSON, SOPHIA HAINES
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:HAINES
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13662 OLD SPRINGHOUSE CT
Mailing Address - Street 2:
Mailing Address - City:LOVETTSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20180-2957
Mailing Address - Country:US
Mailing Address - Phone:540-454-5130
Mailing Address - Fax:
Practice Address - Street 1:13662 OLD SPRINGHOUSE CT
Practice Address - Street 2:
Practice Address - City:LOVETTSVILLE
Practice Address - State:VA
Practice Address - Zip Code:20180-2957
Practice Address - Country:US
Practice Address - Phone:540-454-5130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer