Provider Demographics
NPI:1023757507
Name:GUSTASON, KELSIE
Entity type:Individual
Prefix:
First Name:KELSIE
Middle Name:
Last Name:GUSTASON
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 1:146 GUSTASON DR
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-0794
Mailing Address - Country:US
Mailing Address - Phone:828-644-3561
Mailing Address - Fax:
Practice Address - Street 1:4400 E US 64 ALT STE D
Practice Address - Street 2:
Practice Address - City:MURPHY
Practice Address - State:NC
Practice Address - Zip Code:28906-4752
Practice Address - Country:US
Practice Address - Phone:828-516-1750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14792225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist