Provider Demographics
NPI:1891047783
Name:GUSTAFSON, STEPHANIE BROOKE (MA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BROOKE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 58275
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25358-0275
Mailing Address - Country:US
Mailing Address - Phone:304-744-5000
Mailing Address - Fax:
Practice Address - Street 1:2059 OAKHURST DR.
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309
Practice Address - Country:US
Practice Address - Phone:304-744-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV135101YP2500X
TN2594101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional