Provider Demographics
NPI:1619309564
Name:GUSTAFSON, CAMELYN T (DPT)
Entity Type:Individual
Prefix:
First Name:CAMELYN
Middle Name:T
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CAMELYN
Other - Middle Name:T
Other - Last Name:DILLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2400 WISTERIA DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2689
Mailing Address - Country:US
Mailing Address - Phone:770-982-0102
Mailing Address - Fax:770-982-0130
Practice Address - Street 1:2400 WISTERIA DR
Practice Address - Street 2:SUITE A
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2689
Practice Address - Country:US
Practice Address - Phone:770-982-0102
Practice Address - Fax:770-982-0130
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011088225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
20265I5283Medicare PIN