Provider Demographics
NPI:1033511357
Name:DRATH, DUSTIN
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:DRATH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 RUSSELL DR W
Mailing Address - Street 2:
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-8845
Mailing Address - Country:US
Mailing Address - Phone:920-538-2148
Mailing Address - Fax:
Practice Address - Street 1:500 RUSSELL DR W
Practice Address - Street 2:
Practice Address - City:HOLMEN
Practice Address - State:WI
Practice Address - Zip Code:54636-8845
Practice Address - Country:US
Practice Address - Phone:920-538-2148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5454-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist