Provider Demographics
NPI:1508832056
Name:GUSTAFSON, TRACY MICHELLE (LMSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:MICHELLE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:MICHELLE
Other - Last Name:DATTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1803 WHITES RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-2883
Mailing Address - Country:US
Mailing Address - Phone:269-345-5776
Mailing Address - Fax:269-345-4011
Practice Address - Street 1:1803 WHITES RD
Practice Address - Street 2:SUITE 5
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-2883
Practice Address - Country:US
Practice Address - Phone:269-345-5776
Practice Address - Fax:269-345-4011
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010804721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical