Provider Demographics
NPI:1164124962
Name:GONZAGA-BEAVER, DUSTIN THOMAS (OTR/L)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:THOMAS
Last Name:GONZAGA-BEAVER
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:DUSTIN
Other - Middle Name:THOMAS
Other - Last Name:BEAVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5655 E CALLE CANADA
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-3720
Mailing Address - Country:US
Mailing Address - Phone:657-282-2000
Mailing Address - Fax:
Practice Address - Street 1:2601 AIRPORT DR STE 115
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6133
Practice Address - Country:US
Practice Address - Phone:310-325-7404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-17
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24722225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist