Basic Information
| Provider Information | |||||||||
| NPI: | 1154426922 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUSTAFSON | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUSTAFSON | ||||||||
| OtherFirstName: | LINDA | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8170 MC CORMICK BLVD | ||||||||
| Address2: | C/O DAVKEN #204 | ||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600762920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476730718 | ||||||||
| FaxNumber: | 8476730875 | ||||||||
| Practice Location | |||||||||
| Address1: | 8170 MC CORMICK BLVD | ||||||||
| Address2: | C/O DAVKEN #204 | ||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600762920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476730718 | ||||||||
| FaxNumber: | 8476730875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | IL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.