Provider Demographics
NPI:1295273282
Name:GUSTAFSON, BRANDY (PT)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1178
Mailing Address - Street 2:
Mailing Address - City:PANHANDLE
Mailing Address - State:TX
Mailing Address - Zip Code:79068-1178
Mailing Address - Country:US
Mailing Address - Phone:806-672-6520
Mailing Address - Fax:
Practice Address - Street 1:3440 BELL ST
Practice Address - Street 2:SUITE 306
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-4147
Practice Address - Country:US
Practice Address - Phone:806-331-6084
Practice Address - Fax:806-331-6085
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1114619225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist