Provider Demographics
NPI:1912174616
Name:GUSTAFSON, TAMMY LYNN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:LYNN
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 BRATLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:WASHBURN
Mailing Address - State:WI
Mailing Address - Zip Code:54891
Mailing Address - Country:US
Mailing Address - Phone:715-373-6425
Mailing Address - Fax:715-373-5655
Practice Address - Street 1:706 BRATLEY DRIVE
Practice Address - Street 2:
Practice Address - City:WASHBURN
Practice Address - State:WI
Practice Address - Zip Code:54891
Practice Address - Country:US
Practice Address - Phone:715-373-6425
Practice Address - Fax:715-373-5655
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2402-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist