Provider Demographics
NPI:1396014783
Name:GOLLUS, JENNIFER (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GOLLUS
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7212 TRICIA LN
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:NY
Mailing Address - Zip Code:14025-9641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10674 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:GOWANDA
Practice Address - State:NY
Practice Address - Zip Code:14070-1344
Practice Address - Country:US
Practice Address - Phone:716-532-3325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011379225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics