Provider Demographics
NPI:1871849406
Name:GUSTAFSON, STUART RANDALL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:STUART
Middle Name:RANDALL
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1346 SOUTH 1220 WEST
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058
Mailing Address - Country:US
Mailing Address - Phone:801-361-0050
Mailing Address - Fax:
Practice Address - Street 1:1346 S 1220 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-2286
Practice Address - Country:US
Practice Address - Phone:801-361-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT346226-3501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical