| Doctor Name: | STACY LOUISE GUSTAFSON |
| NPI Number: | 1457723769 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LPCC |
| License Number: | CC1066 |
| Business Practice Address: | 980 1st St N Pine River, MN - 564744508 |
| Business Phone Number: | 2185878036 |
| Business Fax Number: | |
| Mailing Address: | 14639 Whitebirch Ln, Po Box 625 CROSSLAKE |
| State: | MN |
| Postal Code: | 564423074 |
| Phone Number: | 2188215064 |
| Fax Number: | |
| NPI Enumeration Date: | 10/26/2015 |
| NPI Last Update Date: | 10/26/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | CC1066 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |