Provider Demographics
NPI:1417130972
Name:PUSTINSKY, MILES L (OTA/L)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:L
Last Name:PUSTINSKY
Suffix:
Gender:M
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 W STAFFORD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-4408
Mailing Address - Country:US
Mailing Address - Phone:215-842-9043
Mailing Address - Fax:
Practice Address - Street 1:920 GERMANTOWN PIKE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-7401
Practice Address - Country:US
Practice Address - Phone:610-270-9650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP002236L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant