Provider Demographics
NPI:1598820367
Name:GUSTAFSON, DONAE VERBENA (PSY D)
Entity Type:Individual
Prefix:DR
First Name:DONAE
Middle Name:VERBENA
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6120 OREN AVE N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6155
Mailing Address - Country:US
Mailing Address - Phone:651-430-0888
Mailing Address - Fax:651-430-0889
Practice Address - Street 1:6120 OREN AVE N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6155
Practice Address - Country:US
Practice Address - Phone:651-430-0888
Practice Address - Fax:651-430-0889
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 3566103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN000-562-8542OtherAETNA
MN11-5651OtherU CARE
MN76-83570-00Medicaid
MN61-62456OtherMEDICA
MN58G12GUOtherBCBS OF MN
MN76-83570-00OtherMN MA
MNHP16320OtherHEALTHPARTNERS
MN61-62456OtherMEDICA