Provider Demographics
NPI:1558586032
Name:GUSTAFSON, HELEN J (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:HELEN
Middle Name:J
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:HELEN
Other - Middle Name:J
Other - Last Name:MANINT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC SLP
Mailing Address - Street 1:PO BOX 2675
Mailing Address - Street 2:C/O PEDIATRIC MANAGEMENT SVCS
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 CASAS DEL SUR ST
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-1406
Practice Address - Country:US
Practice Address - Phone:817-219-4023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10635235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist