Provider Demographics
NPI:1699391912
Name:GUSTAFSON, JULIET HOPE (LLMSW)
Entity Type:Individual
Prefix:
First Name:JULIET
Middle Name:HOPE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 PRENTIS ST APT 16
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1173
Mailing Address - Country:US
Mailing Address - Phone:734-474-5085
Mailing Address - Fax:
Practice Address - Street 1:20303 KELLY RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48225-1206
Practice Address - Country:US
Practice Address - Phone:313-719-7078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011071051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801107105OtherLARA