Provider Demographics
NPI:1225321342
Name:FANTUZZO, MICHAEL (OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FANTUZZO
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2879 W HARDIES RD
Mailing Address - Street 2:
Mailing Address - City:GIBSONIA
Mailing Address - State:PA
Mailing Address - Zip Code:15044-8203
Mailing Address - Country:US
Mailing Address - Phone:724-444-6090
Mailing Address - Fax:724-444-6092
Practice Address - Street 1:2879 W HARDIES RD
Practice Address - Street 2:
Practice Address - City:GIBSONIA
Practice Address - State:PA
Practice Address - Zip Code:15044-8203
Practice Address - Country:US
Practice Address - Phone:724-444-6090
Practice Address - Fax:724-444-6092
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC011853225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics