Provider Demographics
NPI:1619642519
Name:GUSTAVE, ALTAGRACE LINDSAY
Entity Type:Individual
Prefix:
First Name:ALTAGRACE
Middle Name:LINDSAY
Last Name:GUSTAVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 NE 147TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-2442
Mailing Address - Country:US
Mailing Address - Phone:786-277-7394
Mailing Address - Fax:
Practice Address - Street 1:2780 SW 37TH AVE STE 206
Practice Address - Street 2:
Practice Address - City:COCONUT GROVE
Practice Address - State:FL
Practice Address - Zip Code:33133-2740
Practice Address - Country:US
Practice Address - Phone:305-646-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IMH18061101YM0800X
FLMH22040101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health