=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073441234
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANYA LANE GUSTAFSON LISW-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2026
-----------------------------------------------------
Last Update Date | 05/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 356 BRITTANY LN
-----------------------------------------------------
City | ELYRIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44035-4169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-294-1376
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 356 BRITTANY LN
-----------------------------------------------------
City | ELYRIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44035-4169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-294-1376
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801108663
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I.2002301
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------