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NPI Code Detail

MEDICARE: STEPHANIE BROOKE GUSTAFSON M.A.

MEDICARE: STEPHANIE BROOKE GUSTAFSON M.A.
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
1101YP2500XProfessional Counselor2594TN
2101YP2500XProfessional Counselor135WV

General Provider Information

NPI Number : 1891047783
Entity Type Code : Individual
Provider Name (Legal Business Name) : STEPHANIE BROOKE GUSTAFSON M.A.
Provider Business Mailing Address
First Line : 2406 KANAWHA BLVD E
Second Line :
City : CHARLESTON
State : WV
Zip : 25311-2323
Country : US
Telephone Number : 304-539-0342
Fax Number : 304-202-7879
Provider Business Practice Location Address
First Line : 2406 KANAWHA BLVD E
Second Line :
City : CHARLESTON
State : WV
Zip : 25311-2323
Country : US
Telephone Number : 304-539-0342
Fax Number : 304-202-7879
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/03/2012
Last Update Date : 03/27/2026

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