Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 32000822A | IN |
NPI | 1013116995 |
---|---|
Provider Name | Gwendolyn M Matusz |
First Address | Long Beach, IN 46360-1404 |
Second Address | Portage, IN 46368-5008 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2007 |
Last Update Date | 12/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
32000822A | COTA (01) | IN |