Provider Demographics
NPI:1407070709
Name:GUSHAULIS, THERESA (OTR)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:GUSHAULIS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 NUANGOLA RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-9506
Mailing Address - Country:US
Mailing Address - Phone:570-868-5022
Mailing Address - Fax:
Practice Address - Street 1:3011 NUANGOLA RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN TOP
Practice Address - State:PA
Practice Address - Zip Code:18707-9506
Practice Address - Country:US
Practice Address - Phone:570-868-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC002342L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012893550001Medicaid