Provider Demographics
NPI:1902577976
Name:GUSTAFSON, HEATHER (MT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 W WISCONSIN ST STE 4
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-2493
Mailing Address - Country:US
Mailing Address - Phone:608-269-4511
Mailing Address - Fax:
Practice Address - Street 1:559 BRAUND ST STE 3
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8659
Practice Address - Country:US
Practice Address - Phone:608-783-7735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14207-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist