Provider Demographics
NPI:1760963821
Name:GUSTAFSON, DAYLENE MARIE (RBT, CBT)
Entity Type:Individual
Prefix:
First Name:DAYLENE
Middle Name:MARIE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:RBT, CBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13333 NE BEL RED RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-2332
Mailing Address - Country:US
Mailing Address - Phone:425-559-7809
Mailing Address - Fax:877-669-1490
Practice Address - Street 1:13333 NE BEL RED RD STE 100
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-2332
Practice Address - Country:US
Practice Address - Phone:425-559-7809
Practice Address - Fax:877-669-1490
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB60786345106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician