Provider Demographics
NPI:1669874202
Name:GUSTAFSON, ROSANNA
Entity type:Individual
Prefix:
First Name:ROSANNA
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26001 REDLANDS BLVD
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-7762
Mailing Address - Country:US
Mailing Address - Phone:909-825-7084
Mailing Address - Fax:
Practice Address - Street 1:900 E GILBERT ST COTTAGE # 4
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-0920
Practice Address - Country:US
Practice Address - Phone:909-387-7020
Practice Address - Fax:909-387-7611
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-25
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37127101YM0800X
CA826541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA82654Medicaid