Provider Demographics
NPI:1477545846
Name:GUSTAFSON, EILEEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:EILEEN
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5797
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34611-5797
Mailing Address - Country:US
Mailing Address - Phone:352-428-8463
Mailing Address - Fax:352-597-2074
Practice Address - Street 1:10335 CROSS CREEK BLVD
Practice Address - Street 2:SUITE 23
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2795
Practice Address - Country:US
Practice Address - Phone:352-428-8463
Practice Address - Fax:352-597-2074
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL62831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z085ZMedicare UPIN