Healthcare Provider Details

I. General information

NPI: 1780885467
Provider Name (Legal Business Name): PATRICE ANN GUSTAFSON C.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N HURON ST
CHEBOYGAN MI
49721-1513
US

IV. Provider business mailing address

PO BOX 33
MACKINAW CITY MI
49701-0033
US

V. Phone/Fax

Practice location:
  • Phone: 231-627-4345
  • Fax: 231-627-4491
Mailing address:
  • Phone: 231-627-4345
  • Fax: 231-627-4491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: