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General NPI Number Information
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NPI Number | 1174702922
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Entity Type | Individual
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Provider Name | MARY GUSTAFIK LPC
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Gender | Female
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Dates
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Enumeration Date | 10/29/2007
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Last Update Date | 10/29/2007
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Provider Practice Location Address
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Address Line | 312 S FIRST AVE LOWR LEVEL
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City | SANDPOINT
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State | ID
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Zip | 83864-1202
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Country | US
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Telephone | 208-263-7727
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Fax | 208-263-7728
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Provider Business Mailing Address
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Address Line | 202 E ANTON AVE STE 206
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City | COEUR D ALENE
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State | ID
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Zip | 83815-3779
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Country | US
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Telephone | 208-667-6095
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Fax | 208-667-6173
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 3849
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License Number State | ID
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