Provider Demographics
NPI:1033599550
Name:JUSTAK, TODD M (PT)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:M
Last Name:JUSTAK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:9300 STONESTREET RD
Practice Address - Street 2:SUITE 400
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-2863
Practice Address - Country:US
Practice Address - Phone:502-935-9776
Practice Address - Fax:502-935-9813
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007788A225100000X
KY006561225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist