Provider Demographics
NPI:1710068788
Name:GUSTAVSON, RAY H (MSW)
Entity Type:Individual
Prefix:MR
First Name:RAY
Middle Name:H
Last Name:GUSTAVSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15647 MONTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:VA
Mailing Address - Zip Code:22025-1327
Mailing Address - Country:US
Mailing Address - Phone:703-580-5600
Mailing Address - Fax:
Practice Address - Street 1:2296 OPITZ BLVD STE 270
Practice Address - Street 2:50 SOUTH PICKETT ST, SUITE 224, ALEXANDRIA, VA. 22304
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3345
Practice Address - Country:US
Practice Address - Phone:703-580-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040038811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8919615Medicaid
VA223973Medicare UPIN
VA8919615Medicaid