Provider Demographics
NPI:1700823952
Name:GUSTAFSON, MICHELLE LEE (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1450
Mailing Address - Country:US
Mailing Address - Phone:612-672-4103
Mailing Address - Fax:
Practice Address - Street 1:FAIRVIEW UNIVERSITY HOSPITAL
Practice Address - Street 2:2450 RIVERSIDE AVENUE SOUTH
Practice Address - City:MPLS
Practice Address - State:MN
Practice Address - Zip Code:55454
Practice Address - Country:US
Practice Address - Phone:612-273-5640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical