Provider Demographics
NPI:1780885467
Name:GUSTAFSON, PATRICE ANN (CMT)
Entity type:Individual
Prefix:MRS
First Name:PATRICE
Middle Name:ANN
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:MACKINAW CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49701-0033
Mailing Address - Country:US
Mailing Address - Phone:231-627-4345
Mailing Address - Fax:231-627-4491
Practice Address - Street 1:320 N HURON ST
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-1513
Practice Address - Country:US
Practice Address - Phone:231-627-4345
Practice Address - Fax:231-627-4491
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist