Provider Demographics
NPI:1477659290
Name:GUSTAFSON, KAY MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KAY
Middle Name:MARIE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-1741
Mailing Address - Country:US
Mailing Address - Phone:402-658-2415
Mailing Address - Fax:402-333-2298
Practice Address - Street 1:2501 CAPEHART RD
Practice Address - Street 2:
Practice Address - City:OFFUTT AFB
Practice Address - State:NE
Practice Address - Zip Code:68113-1043
Practice Address - Country:US
Practice Address - Phone:402-294-7411
Practice Address - Fax:402-294-7085
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE069103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE080-66OtherBLUE CROSS BLUE SHIELD
NE080-66OtherBLUE CROSS BLUE SHIELD