Provider Demographics
NPI:1922209873
Name:GUSTAFSON, KATRINA GRACE (MS IN COUNSELING)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:GRACE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MS IN COUNSELING
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:GRACE
Other - Last Name:OLIVEIRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS IN COUNSELING
Mailing Address - Street 1:1861 SILVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94519-1352
Mailing Address - Country:US
Mailing Address - Phone:925-687-0202
Mailing Address - Fax:
Practice Address - Street 1:1861 SILVERWOOD DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94519-1352
Practice Address - Country:US
Practice Address - Phone:925-878-5106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53302101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health