Provider Demographics
NPI:1023313756
Name:GUSTAFSON, DENA JOYE
Entity type:Individual
Prefix:
First Name:DENA
Middle Name:JOYE
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 1:7575 W WASHINGTON AVE
Mailing Address - Street 2:127-127
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-4333
Mailing Address - Country:US
Mailing Address - Phone:702-767-8124
Mailing Address - Fax:
Practice Address - Street 1:7575 W WASHINGTON AVE
Practice Address - Street 2:127-127
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-4333
Practice Address - Country:US
Practice Address - Phone:702-767-8124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker