Basic Information
| Provider Information | |||||||||
| NPI: | 1932353281 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUSTAFSON | ||||||||
| FirstName: | DAWN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 W WACKER DR | ||||||||
| Address2: | SUITE 1020 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606061216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126400329 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4412 S PULASKI RD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606324011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738473123 | ||||||||
| FaxNumber: | 7738473778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2008 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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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 | 225100000X | 070016797 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT38367 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1619980 | 01 | IL | BCBS OF IL | OTHER |