Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC2200X | Clinical Child & Adolescent Psychologist | 736 | KY |
NPI | 1013064112 |
---|---|
Provider Name | Dr. Holly Beth Gustafson |
First Address | Louisville, KY 40217-1417 |
Second Address | Louisville, KY 40217-1417 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2007 |
Last Update Date | 08/07/2007 |