Provider Demographics
NPI:1124122767
Name:GUST, TIM (PHD)
Entity type:Individual
Prefix:DR
First Name:TIM
Middle Name:
Last Name:GUST
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3988 DWIGGINS ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90063-1716
Mailing Address - Country:US
Mailing Address - Phone:323-269-2298
Mailing Address - Fax:323-269-2298
Practice Address - Street 1:3988 DWIGGINS ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90063-1716
Practice Address - Country:US
Practice Address - Phone:323-269-2298
Practice Address - Fax:323-269-2298
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7209103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist