Provider Demographics
NPI:1396933446
Name:EILEEN GUSTAFSON LCSW PA
Entity type:Organization
Organization Name:EILEEN GUSTAFSON LCSW PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:352-428-8463
Mailing Address - Street 1:PO BOX 5797
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34611-5797
Mailing Address - Country:US
Mailing Address - Phone:352-428-8463
Mailing Address - Fax:352-597-2074
Practice Address - Street 1:10335 CROSS CREEK BLVD
Practice Address - Street 2:SUITE 23
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2795
Practice Address - Country:US
Practice Address - Phone:352-428-8463
Practice Address - Fax:352-597-2074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLCSW 6283251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9677Medicare UPIN