Provider Demographics
NPI:1861402166
Name:GUSTAFSON, MIREILLE S (RNCNS)
Entity type:Individual
Prefix:
First Name:MIREILLE
Middle Name:S
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:RNCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 NORTH ST
Mailing Address - Street 2:DEPARTY OF PSYCHIATRY
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201
Mailing Address - Country:US
Mailing Address - Phone:413-664-4541
Mailing Address - Fax:413-662-3311
Practice Address - Street 1:25 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:NORTH ADAMS
Practice Address - State:MA
Practice Address - Zip Code:01247
Practice Address - Country:US
Practice Address - Phone:413-664-4541
Practice Address - Fax:413-662-3311
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA169385364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
R96062Medicare UPIN