Basic Information
| Provider Information | |||||||||
| NPI: | 1669874202 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUSTAFSON | ||||||||
| FirstName: | ROSANNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26001 REDLANDS BLVD | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923737762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 E GILBERT ST COTTAGE # 4 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924150920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093877020 | ||||||||
| FaxNumber: | 9093877611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2014 | ||||||||
| LastUpdateDate: | 05/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 37127 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 82654 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 82654 | 05 | CA | MEDICAID |