Provider Demographics
NPI:1497229363
Name:GUSTAFSON-DOMBECK, SARAH CATHERINE (MA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:CATHERINE
Last Name:GUSTAFSON-DOMBECK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 RANDOLPH ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-2621
Mailing Address - Country:US
Mailing Address - Phone:612-205-4897
Mailing Address - Fax:
Practice Address - Street 1:4150 OLSON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4800
Practice Address - Country:US
Practice Address - Phone:866-522-2472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health