Provider Demographics
NPI:1609146216
Name:GUSTAFSON, ELLEN KRISTEN (DPT)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:KRISTEN
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 S MAIN ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-5447
Mailing Address - Country:US
Mailing Address - Phone:301-607-9096
Mailing Address - Fax:
Practice Address - Street 1:1311 S MAIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:MOUNT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771-5447
Practice Address - Country:US
Practice Address - Phone:301-607-9096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24213225100000X
WAPT 60255109225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist