Provider Demographics
NPI:1881355758
Name:GUSTAVSSON, CLARE (LP)
Entity type:Individual
Prefix:
First Name:CLARE
Middle Name:
Last Name:GUSTAVSSON
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 W END AVE # 11A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5551
Mailing Address - Country:US
Mailing Address - Phone:646-327-5176
Mailing Address - Fax:
Practice Address - Street 1:777 W END AVE # 11A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-5551
Practice Address - Country:US
Practice Address - Phone:646-327-5176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001106102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst