Provider Demographics
NPI:1811599483
Name:GUSTAFSON, MARA CATHERINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARA
Middle Name:CATHERINE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10625 DIXON DR S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98178-2718
Mailing Address - Country:US
Mailing Address - Phone:206-929-0492
Mailing Address - Fax:
Practice Address - Street 1:10625 DIXON DR S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98178-2718
Practice Address - Country:US
Practice Address - Phone:847-827-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY61031462103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist