Provider Demographics
NPI:1396101804
Name:GUSTAFSON, JAMES RAYMOND (OT)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RAYMOND
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11629
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59719-1629
Mailing Address - Country:US
Mailing Address - Phone:406-522-7488
Mailing Address - Fax:406-522-7487
Practice Address - Street 1:536 S. COTTONWOOD RD
Practice Address - Street 2:SUITE 103
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-9505
Practice Address - Country:US
Practice Address - Phone:406-548-6266
Practice Address - Fax:406-548-6269
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4000225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist