Provider Demographics
NPI:1972656122
Name:GUSTAFSON, GRACE RAISSA (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:RAISSA
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:MS
Other - First Name:GRACE
Other - Middle Name:RAISSA
Other - Last Name:BRILLIANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC SLP
Mailing Address - Street 1:359 WEST THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:THOMPSON
Mailing Address - State:CT
Mailing Address - Zip Code:06277
Mailing Address - Country:US
Mailing Address - Phone:860-963-0267
Mailing Address - Fax:
Practice Address - Street 1:PRENET FAMILY HEALTH SERVICES
Practice Address - Street 2:237 MILLBURY ST
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610
Practice Address - Country:US
Practice Address - Phone:508-755-1228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5053235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist