Provider Demographics
NPI:1407425382
Name:MCTISH, JUSTIN THOMAS (OTD, OTR/L, CAPS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:THOMAS
Last Name:MCTISH
Suffix:
Gender:M
Credentials:OTD, OTR/L, CAPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001-1548
Mailing Address - Country:US
Mailing Address - Phone:732-283-2663
Mailing Address - Fax:732-283-2661
Practice Address - Street 1:1050 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:AVENEL
Practice Address - State:NJ
Practice Address - Zip Code:07001-1548
Practice Address - Country:US
Practice Address - Phone:732-504-3649
Practice Address - Fax:732-564-9032
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR0097550225X00000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist