Provider Demographics
NPI:1669520797
Name:GUSTAFSON, MARGARET MARY (MS)
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:MARY
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 PRINGLE RD SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-1533
Mailing Address - Country:US
Mailing Address - Phone:503-588-5330
Mailing Address - Fax:503-540-4473
Practice Address - Street 1:2611 PRINGLE RD SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1533
Practice Address - Country:US
Practice Address - Phone:503-588-5330
Practice Address - Fax:503-540-4473
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20725231H00000X
ORHAS-P-213786237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR162826Medicaid
OR162826Medicaid