Provider Demographics
NPI:1770686750
Name:GUSTUS, CHRISTINE P (MSW/LCSW)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:P
Last Name:GUSTUS
Suffix:
Gender:F
Credentials:MSW/LCSW
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:PEEK
Other - Last Name:GUSTUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:110 SKYLINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2601
Mailing Address - Country:US
Mailing Address - Phone:479-968-1298
Mailing Address - Fax:479-890-5364
Practice Address - Street 1:110 SKYLINE DRIVE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2601
Practice Address - Country:US
Practice Address - Phone:479-968-1298
Practice Address - Fax:479-890-5364
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1063-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S875OtherAR BCBS
AR5S875Medicare ID - Type Unspecified