1659324713 NPI number — MRS. JUDY KAY GUSTAFSON LCSW, CAC

Table of content: MRS. JUDY KAY GUSTAFSON LCSW, CAC (NPI 1659324713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659324713 NPI number — MRS. JUDY KAY GUSTAFSON LCSW, CAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUSTAFSON
Provider First Name:
JUDY
Provider Middle Name:
KAY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW, CAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659324713
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5052
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIMERICK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19468-0952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-495-1530
Provider Business Mailing Address Fax Number:
610-495-7840

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3310 W RIDGE PIKE
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
POTTSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19464-3450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-495-1530
Provider Business Practice Location Address Fax Number:
610-495-7840
Provider Enumeration Date:
05/18/2006

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: 101YA0400X , with the licence number:  2707 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1041C0700X , with the licence number: CW015335 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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