Provider Demographics
NPI:1932542180
Name:GUSTAFSON, LISA (PHD, PLLC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PHD, PLLC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:200 E MAIN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3857
Mailing Address - Country:US
Mailing Address - Phone:701-400-5472
Mailing Address - Fax:
Practice Address - Street 1:200 E MAIN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-3857
Practice Address - Country:US
Practice Address - Phone:701-400-5472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2013-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND474103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical