Healthcare Provider Details

I. General information

NPI: 1720068059
Provider Name (Legal Business Name): JOHN L GUSTAVSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 N 8TH ST SUITE 204
GRAND JUNCTION CO
81501-8857
US

IV. Provider business mailing address

2530 N 8TH ST SUITE 204
GRAND JUNCTION CO
81501-8857
US

V. Phone/Fax

Practice location:
  • Phone: 970-245-3505
  • Fax:
Mailing address:
  • Phone: 970-245-3505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY.0000987
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: