Individual
NISSA SAGE GUSTAFSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LSW
Contact information
Practice address
112 E ALLEN ST UNIT 3, PHILADELPHIA, PA 19125-4189
(215) 278-9444
Mailing address
1107 LINN ST, PHILADELPHIA, PA 19147-6307
(845) 750-2351
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
SW141961
PA
Other
Enumeration date
05/31/2025
Last updated
05/31/2025
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