Provider Demographics
NPI:1013064112
Name:GUSTAFSON, HOLLY BETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:BETH
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1169 EASTERN PKWY
Mailing Address - Street 2:STE 431
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1417
Mailing Address - Country:US
Mailing Address - Phone:502-212-1032
Mailing Address - Fax:502-212-1033
Practice Address - Street 1:1169 EASTERN PKWY
Practice Address - Street 2:STE 431
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1417
Practice Address - Country:US
Practice Address - Phone:502-212-1032
Practice Address - Fax:502-212-1033
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY736103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent