1770686750 NPI number — CHRISTINE P GUSTUS MSW/LCSW

Table of content: CHRISTINE P GUSTUS MSW/LCSW (NPI 1770686750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770686750 NPI number — CHRISTINE P GUSTUS MSW/LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUSTUS
Provider First Name:
CHRISTINE
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW/LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GUSTUS
Provider Other First Name:
CHRISTINE
Provider Other Middle Name:
PEEK
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1770686750
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 SKYLINE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSSELLVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72801-2601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-968-1298
Provider Business Mailing Address Fax Number:
479-890-5364

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 SKYLINE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72801-2601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-968-1298
Provider Business Practice Location Address Fax Number:
479-890-5364
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  1063-C , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5S875 . This is a "AR BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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