Provider Demographics
NPI:1154426922
Name:GUSTAFSON, LINDA K (PHD)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:K
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LINDA
Other - Middle Name:K
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:8170 MC CORMICK BLVD
Mailing Address - Street 2:C/O DAVKEN #204
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-2920
Mailing Address - Country:US
Mailing Address - Phone:847-673-0718
Mailing Address - Fax:847-673-0875
Practice Address - Street 1:8170 MC CORMICK BLVD
Practice Address - Street 2:C/O DAVKEN #204
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-2920
Practice Address - Country:US
Practice Address - Phone:847-673-0718
Practice Address - Fax:847-673-0875
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL337040Medicare ID - Type Unspecified