Provider Demographics
NPI:1134311657
Name:GUSHO, BETTY KALLIS
Entity Type:Individual
Prefix:MRS
First Name:BETTY
Middle Name:KALLIS
Last Name:GUSHO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1195 LYONHURST ST
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-1015
Mailing Address - Country:US
Mailing Address - Phone:248-644-2465
Mailing Address - Fax:
Practice Address - Street 1:26091 SHERWOOD AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-6602
Practice Address - Country:US
Practice Address - Phone:586-755-4711
Practice Address - Fax:586-755-7211
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501300666225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist