Provider Demographics
NPI:1750058988
Name:GUSTAFSON, EMILY ANN (LMFT, ATR)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ANN
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LMFT, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17999 140TH AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-4095
Mailing Address - Country:US
Mailing Address - Phone:320-420-8179
Mailing Address - Fax:
Practice Address - Street 1:110 2ND ST S STE 235
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1313
Practice Address - Country:US
Practice Address - Phone:320-200-7894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3442106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty