Provider Demographics
NPI:1801591128
Name:GUSTAFSON, NATHANAEL
Entity type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 WHALEN RD
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-1765
Mailing Address - Country:US
Mailing Address - Phone:608-229-1643
Mailing Address - Fax:
Practice Address - Street 1:1118 STARLIGHT DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2727
Practice Address - Country:US
Practice Address - Phone:815-298-4872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician