Provider Demographics
NPI:1972892792
Name:GUSTAW, DIANE (QMHA)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:GUSTAW
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8777 W MAULE AVE
Mailing Address - Street 2:2074
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-4868
Mailing Address - Country:US
Mailing Address - Phone:631-839-2462
Mailing Address - Fax:
Practice Address - Street 1:8777 W MAULE AVENUE
Practice Address - Street 2:2074
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-4894
Practice Address - Country:US
Practice Address - Phone:631-839-2462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner