Basic Information
| Provider Information | |||||||||
| NPI: | 1750532578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUSTAFSON | ||||||||
| FirstName: | ANNEKE | ||||||||
| MiddleName: | BRITT | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 UNIVERSITY AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503142343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152481447 | ||||||||
| FaxNumber: | 5152481440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 UNIVERSITY AVE | ||||||||
| Address2: | STE 120 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503142343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152481500 | ||||||||
| FaxNumber: | 5152481510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2008 | ||||||||
| LastUpdateDate: | 08/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 01296 | IA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 007134 | IA | N | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 107314000 | 01 | IA | IOWA PLAN | OTHER |