Provider Demographics
NPI:1932436789
Name:GUSTAFSON, CHRISTIE IVA (LPTA)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:IVA
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LPTA
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 DR
Mailing Address - Street 2:
Mailing Address - City:WASHBURN
Mailing Address - State:WI
Mailing Address - Zip Code:54891-1143
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?:No
Enumeration Date:2009-11-13
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI565-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20194600Medicaid