Provider Demographics
NPI:1780458448
Name:GUSTAVUS, ROBIN STEPHANIE (LMT, BCTMB)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:STEPHANIE
Last Name:GUSTAVUS
Suffix:
Gender:F
Credentials:LMT, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9001 E 89TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64138-4522
Mailing Address - Country:US
Mailing Address - Phone:907-301-5814
Mailing Address - Fax:
Practice Address - Street 1:6556 JOHNSON DR
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:KS
Practice Address - Zip Code:66202-2615
Practice Address - Country:US
Practice Address - Phone:913-432-4780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008018015225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist