Provider Demographics
NPI:1689989550
Name:GUSTAFSON, CAMILLE MICHELLE
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:MICHELLE
Last Name:GUSTAFSON
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 1:821 1/2 WEST ST
Mailing Address - Street 2:
Mailing Address - City:MANTORVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55955-8056
Mailing Address - Country:US
Mailing Address - Phone:507-384-2916
Mailing Address - Fax:
Practice Address - Street 1:1552 MALL DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-3110
Practice Address - Country:US
Practice Address - Phone:319-351-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002077225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist