Provider Demographics
NPI:1942591466
Name:GUSTAFSON, ERIN MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:MARIE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:MARIE
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:6501 S PROMONTORY DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-1003
Mailing Address - Country:US
Mailing Address - Phone:773-256-5778
Mailing Address - Fax:
Practice Address - Street 1:6501 S PROMONTORY DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-1003
Practice Address - Country:US
Practice Address - Phone:773-256-5778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-02
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0177361041C0700X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical