Provider Demographics
NPI:1629356977
Name:GUSTAVSON, AMY STACK (MS, LMHC)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:STACK
Last Name:GUSTAVSON
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3726 HILAIRE WAY
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-2710
Mailing Address - Country:US
Mailing Address - Phone:718-352-2140
Mailing Address - Fax:718-352-2491
Practice Address - Street 1:251 LAFAYETTE ST FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-4067
Practice Address - Country:US
Practice Address - Phone:212-570-1693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002405-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health