Healthcare Provider Details

I. General information

NPI: 1356598841
Provider Name (Legal Business Name): GAIL SUSAN GUSTAFSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 NE 3RD ST
GRESHAM OR
97030-7403
US

IV. Provider business mailing address

PO BOX 2114
GRESHAM OR
97030-0604
US

V. Phone/Fax

Practice location:
  • Phone: 503-313-5369
  • Fax:
Mailing address:
  • Phone: 503-313-5369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number7795
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: