Provider Demographics
NPI:1306889530
Name:GUSTAFSON, CHERIE (MA)
Entity type:Individual
Prefix:MS
First Name:CHERIE
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MARKET STREET
Mailing Address - Street 2:SUITE 1A BOX 212
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3646
Mailing Address - Country:US
Mailing Address - Phone:207-808-9820
Mailing Address - Fax:
Practice Address - Street 1:505R OCEAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-6615
Practice Address - Country:US
Practice Address - Phone:207-808-9820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC1639101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health