Provider Demographics
NPI:1891182713
Name:GUSTAFSON, HOWARD (LCSW)
Entity Type:Individual
Prefix:
First Name:HOWARD
Middle Name:
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 1:324 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3632
Mailing Address - Country:US
Mailing Address - Phone:317-714-7667
Mailing Address - Fax:317-634-0253
Practice Address - Street 1:324 N PARK AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3632
Practice Address - Country:US
Practice Address - Phone:317-714-7667
Practice Address - Fax:317-634-0253
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001536A101YA0400X
IN34001491A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical