Provider Demographics
NPI:1871483248
Name:GUSTAFSON, EMILY ROSE (LICSW)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ROSE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9774 MAGNOLIA ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5431
Mailing Address - Country:US
Mailing Address - Phone:763-807-5707
Mailing Address - Fax:
Practice Address - Street 1:15243 NOWTHEN BLVD NW
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:MN
Practice Address - Zip Code:55303-6138
Practice Address - Country:US
Practice Address - Phone:612-900-0233
Practice Address - Fax:866-627-0910
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-08
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN192271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical