Provider Demographics
NPI:1649754003
Name:GUSTAFSON, EVA B (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:B
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 S PITT ST
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-3220
Mailing Address - Country:US
Mailing Address - Phone:202-751-5099
Mailing Address - Fax:
Practice Address - Street 1:42 S PITT ST
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17013-3220
Practice Address - Country:US
Practice Address - Phone:202-751-5099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL014175235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist