Provider Demographics
NPI:1679073969
Name:GUSTAFSON, KAYLIE MARLENE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:KAYLIE
Middle Name:MARLENE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33985 MANTA CT
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-4507
Mailing Address - Country:US
Mailing Address - Phone:949-336-2569
Mailing Address - Fax:
Practice Address - Street 1:33985 MANTA CT
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-4507
Practice Address - Country:US
Practice Address - Phone:949-336-2569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26817235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist