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General NPI Number Information
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NPI Number | 1710068788
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Entity Type | Individual
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Provider Name | RAY H GUSTAVSON M.S.W.
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Gender | Male
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Dates
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Enumeration Date | 10/18/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 2296 OPITZ BLVD STE 270 50 SOUTH PICKETT ST, SUITE 224, ALEXANDRIA, VA. 22304
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City | WOODBRIDGE
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State | VA
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Zip | 22191-3345
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Country | US
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Telephone | 703-580-5600
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Fax |
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Provider Business Mailing Address
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Address Line | 15647 MONTVIEW DR
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City | MONTCLAIR
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State | VA
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Zip | 22025-1327
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Country | US
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Telephone | 703-580-5600
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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 | 0904003881
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License Number State | VA
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