MEDICARE: MR. RAY H GUSTAVSON M.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904003881	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710068788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RAY H GUSTAVSON M.S.W.

Provider Business Mailing Address
First Line	:	15647 MONTVIEW DR
Second Line	:
City	:	MONTCLAIR
State	:	VA
Zip	:	22025-1327
Country	:	US
Telephone Number	:	703-580-5600
Fax Number	:

Provider Business Practice Location Address
First Line	:	2296 OPITZ BLVD STE 270
Second Line	:	50 SOUTH PICKETT ST, SUITE 224, ALEXANDRIA, VA. 22304
City	:	WOODBRIDGE
State	:	VA
Zip	:	22191-3345
Country	:	US
Telephone Number	:	703-580-5600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	07/09/2007

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