Provider Demographics
NPI:1518642735
Name:GUSTAVE, JONATHAN (LMFT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:GUSTAVE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2762 WHITE ISLE LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-7864
Mailing Address - Country:US
Mailing Address - Phone:954-947-7425
Mailing Address - Fax:
Practice Address - Street 1:2762 WHITE ISLE LN
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-7864
Practice Address - Country:US
Practice Address - Phone:954-947-7425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT4652101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health