Healthcare Provider Details

I. General information

NPI: 1861402166
Provider Name (Legal Business Name): MIREILLE S GUSTAFSON RNCNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MARSHALL ST
NORTH ADAMS MA
01247
US

IV. Provider business mailing address

725 NORTH ST DEPARTY OF PSYCHIATRY
PITTSFIELD MA
01201
US

V. Phone/Fax

Practice location:
  • Phone: 413-664-4541
  • Fax: 413-662-3311
Mailing address:
  • Phone: 413-664-4541
  • Fax: 413-662-3311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number169385
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: