Provider Demographics
NPI:1972682557
Name:FREEMAN GUSTAFSON, CARL SCOTT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:SCOTT
Last Name:FREEMAN GUSTAFSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:CARL
Other - Middle Name:SCOTT
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:104 BRIGANTINE DR
Mailing Address - Street 2:
Mailing Address - City:HATCHVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02536-3958
Mailing Address - Country:US
Mailing Address - Phone:508-563-5037
Mailing Address - Fax:
Practice Address - Street 1:1074 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST BARNSTABLE
Practice Address - State:MA
Practice Address - Zip Code:02668-1142
Practice Address - Country:US
Practice Address - Phone:508-362-1180
Practice Address - Fax:508-362-7048
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8060103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0502944Medicaid
MAW06208Medicare ID - Type Unspecified