1669556437 NPI number — WILLIAM THOMAS GUSTAVUS PHD LPC

Table of content: WILLIAM THOMAS GUSTAVUS PHD LPC (NPI 1669556437)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669556437 NPI number — WILLIAM THOMAS GUSTAVUS PHD LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUSTAVUS
Provider First Name:
WILLIAM
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD LPC
Provider Gender Code:
M

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:
1669556437
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 2371
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROWNWOOD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-642-4883
Provider Business Mailing Address Fax Number:
325-643-6048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 HWY 377 SOUTH
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
BROWNWOOD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-642-4883
Provider Business Practice Location Address Fax Number:
325-643-6048
Provider Enumeration Date:
10/25/2006

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: 101YP2500X , with the licence number:  12486 , 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)





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