Provider Demographics
NPI:1245911874
Name:GUSTAVE, LIZA (MS, LPC, LCDC)
Entity type:Individual
Prefix:
First Name:LIZA
Middle Name:
Last Name:GUSTAVE
Suffix:
Gender:F
Credentials:MS, LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 PARKMILL DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-6473
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3600 PARKMILL DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-6473
Practice Address - Country:US
Practice Address - Phone:571-243-2877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15367101YA0400X
TX84924101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)