Basic Information
Provider Information | |||||||||
NPI: | 1629056585 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUSTAFSON | ||||||||
FirstName: | TORI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5865 | ||||||||
Address2: |   | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794085865 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8067432898 | ||||||||
FaxNumber: | 8067432787 | ||||||||
Practice Location | |||||||||
Address1: | 3601 4TH ST | ||||||||
Address2: | SUITE 2A300 | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794300002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8067435678 | ||||||||
FaxNumber: | 8067435670 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/02/2006 | ||||||||
LastUpdateDate: | 11/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 50936 | TX | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   |
ID Information
ID | Type | State | Issuer | Description | 201021516 | 05 | NM |   | MEDICAID | 80138A | 01 | TX | BC/BS | OTHER | 80761Z | 01 | TX | HMO BLUE | OTHER | 100671140A | 05 | OK |   | MEDICAID | 022426302 | 05 | TX |   | MEDICAID | 201021516 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER | Q6377 | 05 | NM |   | MEDICAID | 022426301 | 05 | TX |   | MEDICAID | A269 | 01 | NM | TRIWEST | OTHER |