Provider Demographics
NPI:1922268721
Name:GUSTAVSON, HOLLY DYAN (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:DYAN
Last Name:GUSTAVSON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1062 GUAM DR APT B
Mailing Address - Street 2:
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93041-3918
Mailing Address - Country:US
Mailing Address - Phone:832-969-7040
Mailing Address - Fax:
Practice Address - Street 1:2641 S C ST
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93033-4502
Practice Address - Country:US
Practice Address - Phone:805-487-7840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-15
Last Update Date:2008-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15235235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist