Provider Demographics
NPI:1851778757
Name:GUSTAFSON, WAYNE ERIC (DMIN)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:ERIC
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 RACHEL CARSON WAY
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-8402
Mailing Address - Country:US
Mailing Address - Phone:607-857-0003
Mailing Address - Fax:
Practice Address - Street 1:224 FOREST HOME DR
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-2747
Practice Address - Country:US
Practice Address - Phone:607-857-0003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYLMHC 002006101YM0800X
101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral