Provider Demographics
NPI:1649212390
Name:GUSTAFSON, DANIEL T (PHD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:T
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 N HIGH POINT RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-2236
Mailing Address - Country:US
Mailing Address - Phone:608-824-4800
Mailing Address - Fax:608-824-4938
Practice Address - Street 1:752 N HIGH POINT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-2236
Practice Address - Country:US
Practice Address - Phone:608-824-4000
Practice Address - Fax:608-824-4938
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2188-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1649212390Medicaid
WI39145700Medicaid
WI60302OtherDEAN HEALTH INSURANCE
Q21246Medicare UPIN