Provider Demographics
NPI:1104423409
Name:GUSTAFSON, DEANNE MARIE
Entity type:Individual
Prefix:
First Name:DEANNE
Middle Name:MARIE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17200 TEAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-5406
Mailing Address - Country:US
Mailing Address - Phone:708-536-8874
Mailing Address - Fax:
Practice Address - Street 1:1301 W COSSITT AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2145
Practice Address - Country:US
Practice Address - Phone:708-354-5730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1884039103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool