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General NPI Number Information
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NPI Number | 1871483248
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Entity Type | Individual
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Provider Name | EMILY ROSE GUSTAFSON LICSW
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Gender | Female
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Dates
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Enumeration Date | 07/08/2025
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Last Update Date | 07/08/2025
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Provider Practice Location Address
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Address Line | 15243 NOWTHEN BLVD NW
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City | RAMSEY
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State | MN
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Zip | 55303-6138
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Country | US
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Telephone | 612-900-0233
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Fax | 866-627-0910
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Provider Business Mailing Address
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Address Line | 9774 MAGNOLIA ST NW
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City | COON RAPIDS
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State | MN
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Zip | 55433-5431
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Country | US
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Telephone | 763-807-5707
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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 | 19227
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License Number State | MN
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