1558586032 NPI number — HELEN J GUSTAFSON MS CCC SLP

Table of content: HELEN J GUSTAFSON MS CCC SLP (NPI 1558586032)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558586032 NPI number — HELEN J GUSTAFSON MS CCC SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUSTAFSON
Provider First Name:
HELEN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS CCC SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MANINT
Provider Other First Name:
HELEN
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS CCC SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1558586032
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2675
Provider Second Line Business Mailing Address:
C/O PEDIATRIC MANAGEMENT SVCS
Provider Business Mailing Address City Name:
WEATHERFORD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76087
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 CASAS DEL SUR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANBURY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76049-1406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-219-4023
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  10635 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)