Provider Demographics
NPI:1669011920
Name:GUSTAFSON, KATY (LCPC)
Entity type:Individual
Prefix:
First Name:KATY
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:KATY
Other - Middle Name:
Other - Last Name:JANOUSEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LGPC
Mailing Address - Street 1:5518 CHESHIRE MEADOWS WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-3226
Mailing Address - Country:US
Mailing Address - Phone:402-750-3668
Mailing Address - Fax:
Practice Address - Street 1:4424 MONTGOMERY AVE STE 201
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-4436
Practice Address - Country:US
Practice Address - Phone:240-560-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP9970101YM0800X
MDLC12771101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health