Provider Demographics
NPI:1942953583
Name:GUSTAFSON, KAELYNNE
Entity Type:Individual
Prefix:
First Name:KAELYNNE
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5107 351ST ST E
Mailing Address - Street 2:
Mailing Address - City:EATONVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98328-9717
Mailing Address - Country:US
Mailing Address - Phone:253-886-3039
Mailing Address - Fax:
Practice Address - Street 1:8811 S TACOMA WAY STE 204&206
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98499-4595
Practice Address - Country:US
Practice Address - Phone:253-559-0323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician