Healthcare Provider Details

I. General information

NPI: 1770447179
Provider Name (Legal Business Name): THERESA GUSTAVESON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 DANBY RD STE 201-M
ITHACA NY
14850-5778
US

IV. Provider business mailing address

1182 CHENANGO ST
BINGHAMTON NY
13901-1653
US

V. Phone/Fax

Practice location:
  • Phone: 607-360-6602
  • Fax:
Mailing address:
  • Phone: 607-772-6904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number120632
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: