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General NPI Number Information
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NPI Number | 1346451523
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Entity Type | Individual
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Provider Name | ANDREA L. GUSTAFSON L.C.S.W., L.M.T.
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Gender | Female
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Dates
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Enumeration Date | 05/27/2007
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Last Update Date | 11/10/2010
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Provider Practice Location Address
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Address Line | 1808 FOLSOM ST
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City | EAU CLAIRE
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State | WI
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Zip | 54703-2579
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Country | US
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Telephone | 715-404-9031
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Fax |
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Provider Business Mailing Address
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Address Line | 1010 PUMPHOUSE RD UNIT C
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City | CHIPPEWA FALLS
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State | WI
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Zip | 54729-4041
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Country | US
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Telephone | 715-861-3108
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Fax |
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 7649-123
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 4982-146
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License Number State | WI
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