Provider Demographics
NPI:1831794973
Name:GUSTAFSON, KASSONDRA LOROL (LPCC)
Entity type:Individual
Prefix:
First Name:KASSONDRA
Middle Name:LOROL
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:KASSONDRA
Other - Middle Name:LOROL
Other - Last Name:LINBO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 28TH AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-5241
Practice Address - Country:US
Practice Address - Phone:320-214-8558
Practice Address - Fax:320-235-2733
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health