Healthcare Provider Details

I. General information

NPI: 1013064112
Provider Name (Legal Business Name): HOLLY BETH GUSTAFSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1169 EASTERN PKWY STE 431
LOUISVILLE KY
40217-1417
US

IV. Provider business mailing address

1169 EASTERN PKWY STE 431
LOUISVILLE KY
40217-1417
US

V. Phone/Fax

Practice location:
  • Phone: 502-212-1032
  • Fax: 502-212-1033
Mailing address:
  • Phone: 502-212-1032
  • Fax: 502-212-1033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number736
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: