Provider Demographics
NPI:1689748063
Name:GUSTAFSON, GRETA H (LCSW)
Entity Type:Individual
Prefix:MS
First Name:GRETA
Middle Name:H
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9902 3RD AVE
Mailing Address - Street 2:2W
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-7938
Mailing Address - Country:US
Mailing Address - Phone:718-836-7528
Mailing Address - Fax:718-836-2045
Practice Address - Street 1:19 W 34TH ST
Practice Address - Street 2:PENTHOUSE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3006
Practice Address - Country:US
Practice Address - Phone:212-947-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR040510-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN9824Medicare ID - Type Unspecified