Individual
ROBERTA GUSTAFSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMSW
Contact information
Practice address
1501 BENCH RD, POCATELLO, ID 83201-2443
(208) 242-3044
Mailing address
344 N 15TH AVE APT 9A, POCATELLO, ID 83201-4042
(208) 957-1136
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
LMSW-33483
ID
Other
Enumeration date
12/30/2015
Last updated
12/30/2015
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