Provider Demographics
NPI:1578276598
Name:GUSTAFSON, ELIZABETH (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7433 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-1619
Mailing Address - Country:US
Mailing Address - Phone:773-338-8778
Mailing Address - Fax:
Practice Address - Street 1:7433 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-1619
Practice Address - Country:US
Practice Address - Phone:773-338-8778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056004727225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty