Provider Demographics
NPI:1871155648
Name:GUSTKE, JONATHAN (COTA/L)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:GUSTKE
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 HASKINS LN N
Mailing Address - Street 2:
Mailing Address - City:HILTON
Mailing Address - State:NY
Mailing Address - Zip Code:14468-8957
Mailing Address - Country:US
Mailing Address - Phone:585-766-1991
Mailing Address - Fax:
Practice Address - Street 1:95 JOHN MUIR DRIVE
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14228
Practice Address - Country:US
Practice Address - Phone:800-543-9399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010091-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant