Provider Demographics
NPI:1063768976
Name:GUSTAF, ERIANNE MARIE (DPT)
Entity type:Individual
Prefix:
First Name:ERIANNE
Middle Name:MARIE
Last Name:GUSTAF
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 4TH AVE W
Mailing Address - Street 2:#206
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98119-4482
Mailing Address - Country:US
Mailing Address - Phone:612-251-3098
Mailing Address - Fax:
Practice Address - Street 1:4455 148TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3120
Practice Address - Country:US
Practice Address - Phone:425-861-6255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-29
Last Update Date:2012-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60288336225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist