=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902421415
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN DANIEL GUSTMAN PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2020
-----------------------------------------------------
Last Update Date | 02/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 399 LAUREL ST STE 9
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94118-1952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-593-1323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 399 LAUREL ST STE 9
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94118-1952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-295-5537
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY.0005139
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TB0200X
-----------------------------------------------------
Taxonomy Name | Cognitive & Behavioral Psychologist
-----------------------------------------------------
License Number | PSY33397
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | CTC-200059350
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | PSY33397
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------