MEDICARE: MR. ROBERT A GUSTAFSON LCSW

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	21795	TX

General Provider Information

NPI Number	:	1811907454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT A GUSTAFSON LCSW

Provider Business Mailing Address
First Line	:	6107 AMICABLE DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76016-2003
Country	:	US
Telephone Number	:	817-937-7417
Fax Number	:

Provider Business Practice Location Address
First Line	:	2707 AIRPORT FWY STE 225
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-2370
Country	:	US
Telephone Number	:	817-937-7417
Fax Number	:

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

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	07/08/2007

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