Healthcare Provider Details

I. General information

NPI: 1639140312
Provider Name (Legal Business Name): LISA ANN GUSTAVSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 E 3900 S SUITE A170
SALT LAKE CITY UT
84124-1215
US

IV. Provider business mailing address

1141 E 3900 S SUITE A170
SALT LAKE CITY UT
84124-1215
US

V. Phone/Fax

Practice location:
  • Phone: 801-284-4990
  • Fax:
Mailing address:
  • Phone: 801-284-4990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number117014-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: