Provider Demographics
NPI:1396819231
Name:GUSKY-SHARP, KATHLEEN NONE (OTR)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:NONE
Last Name:GUSKY-SHARP
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:NONE
Other - Last Name:GUSKY-SHARP
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR
Mailing Address - Street 1:105 VISTA VIEW DR
Mailing Address - Street 2:105 VISTA VIEW DR.,
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425-3373
Mailing Address - Country:US
Mailing Address - Phone:707-894-7409
Mailing Address - Fax:
Practice Address - Street 1:105 VISTA VIEW DR
Practice Address - Street 2:105 VISTA VIEW DR.,
Practice Address - City:CLOVERDALE
Practice Address - State:CA
Practice Address - Zip Code:95425-3373
Practice Address - Country:US
Practice Address - Phone:707-894-7409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACAOT#12171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA 12OtherNBCOT AA060681