Provider Demographics
NPI:1801177316
Name:GUSTIN, JILL M (LMFT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:GUSTIN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 ORISKANY BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITESBORO
Mailing Address - State:NY
Mailing Address - Zip Code:13492-1422
Mailing Address - Country:US
Mailing Address - Phone:315-768-7181
Mailing Address - Fax:315-768-7182
Practice Address - Street 1:327 ORISKANY BLVD
Practice Address - Street 2:
Practice Address - City:WHITESBORO
Practice Address - State:NY
Practice Address - Zip Code:13492-1422
Practice Address - Country:US
Practice Address - Phone:315-768-7181
Practice Address - Fax:315-768-7182
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000901106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist