Provider Demographics
NPI:1306975784
Name:GUSTAFSON, JUDITH M (LMP)
Entity type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:M
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MS
Other - First Name:J
Other - Middle Name:MARIANA
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:6231 188TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98037-7250
Mailing Address - Country:US
Mailing Address - Phone:425-208-1996
Mailing Address - Fax:
Practice Address - Street 1:6231 188TH ST SW
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98037-7250
Practice Address - Country:US
Practice Address - Phone:425-208-1996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019706225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist