Provider Demographics
NPI:1861952194
Name:GUSTAFSON, LORI B (PTA)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:B
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3034 COUNTY ROAD 611
Mailing Address - Street 2:
Mailing Address - City:VALLEY HEAD
Mailing Address - State:AL
Mailing Address - Zip Code:35989-4623
Mailing Address - Country:US
Mailing Address - Phone:912-996-3567
Mailing Address - Fax:855-232-8604
Practice Address - Street 1:3034 COUNTY ROAD 611
Practice Address - Street 2:
Practice Address - City:VALLEY HEAD
Practice Address - State:AL
Practice Address - Zip Code:35989-4623
Practice Address - Country:US
Practice Address - Phone:912-996-3567
Practice Address - Fax:855-232-8604
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7501225200000X
ALPTA10177225200000X
KS14-03493225200000X
GAPTA004592225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant