Provider Demographics
NPI:1619309564
Name:GUSTAFSON, CAMELYN T (DPT)
Entity type:Individual
Prefix:
First Name:CAMELYN
Middle Name:T
Last Name:GUSTAFSON
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:CAMELYN
Other - Middle Name:T
Other - Last Name:DILLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1130 N CHURCH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1041
Mailing Address - Country:US
Mailing Address - Phone:336-375-2301
Mailing Address - Fax:336-375-2315
Practice Address - Street 1:1130 N CHURCH ST STE 100
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1041
Practice Address - Country:US
Practice Address - Phone:770-982-0102
Practice Address - Fax:770-982-0130
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP15718225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
20265I5283Medicare PIN