Provider Demographics
NPI:1194937516
Name:GUSTAFSON, CHRISTINE M (PT)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:M
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10808 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072-9456
Mailing Address - Country:US
Mailing Address - Phone:815-624-2816
Mailing Address - Fax:
Practice Address - Street 1:3616 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-2159
Practice Address - Country:US
Practice Address - Phone:815-877-5932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070003815225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist