Provider Demographics
NPI:1750677811
Name:GUSTAFSON-CLUM, ANNA MARIE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:ANNA
Middle Name:MARIE
Last Name:GUSTAFSON-CLUM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 LONE STAR DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75212-6313
Mailing Address - Country:US
Mailing Address - Phone:469-533-2886
Mailing Address - Fax:214-533-2886
Practice Address - Street 1:2535 LONE STAR DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75212-6313
Practice Address - Country:US
Practice Address - Phone:469-533-2886
Practice Address - Fax:214-533-2886
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37038171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator