Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103K00000X | Behavior Analyst | 1-18-29820 | CT |
NPI | 1003331471 |
---|---|
Provider Name | Mrs. Denae Justine Gustafson |
First Address | Cromwell, CT 06416-4405 |
Second Address | Cromwell, CT 06416 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/08/2017 |
Last Update Date | 11/07/2018 |