Provider Demographics
NPI:1508759382
Name:GUSTAFSON, NISSA SAGE (LSW)
Entity type:Individual
Prefix:
First Name:NISSA
Middle Name:SAGE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 LINN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-6307
Mailing Address - Country:US
Mailing Address - Phone:845-750-2351
Mailing Address - Fax:
Practice Address - Street 1:112 E ALLEN ST UNIT 3
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-4189
Practice Address - Country:US
Practice Address - Phone:215-278-9444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-31
Last Update Date:2025-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW141961104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker