Provider Demographics
NPI:1720068059
Name:GUSTAVSON, JOHN L (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:GUSTAVSON
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 1:2530 N 8TH ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8857
Mailing Address - Country:US
Mailing Address - Phone:970-245-3505
Mailing Address - Fax:
Practice Address - Street 1:2530 N 8TH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8857
Practice Address - Country:US
Practice Address - Phone:970-245-3505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0000987103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07987001Medicaid
COC64326Medicare PIN
COR18691Medicare UPIN