MEDICARE: STEPHANIE BROOKE GUSTAFSON M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	135	WV
2	101YP2500X	Professional Counselor	2594	TN

General Provider Information

NPI Number	:	1891047783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE BROOKE GUSTAFSON M.A.

Provider Business Mailing Address
First Line	:	PO BOX 58275
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25358-0275
Country	:	US
Telephone Number	:	304-744-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2059 OAKHURST DR.
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25309
Country	:	US
Telephone Number	:	304-744-5000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2012
Last Update Date	:	10/03/2012

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