Provider Demographics
NPI:1932692647
Name:GUSTAFSON, KRISTINE SHIRLEY (LPC)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:SHIRLEY
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 S MOFFET AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-2618
Mailing Address - Country:US
Mailing Address - Phone:417-291-3093
Mailing Address - Fax:
Practice Address - Street 1:123 S MOFFET AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-2618
Practice Address - Country:US
Practice Address - Phone:417-291-3093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018002420101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty