Provider Demographics
NPI:1467058677
Name:CUSTER, GLORIA JUNE (COTA)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:JUNE
Last Name:CUSTER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-4406
Mailing Address - Country:US
Mailing Address - Phone:785-650-2368
Mailing Address - Fax:
Practice Address - Street 1:320 W 8TH ST
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-4406
Practice Address - Country:US
Practice Address - Phone:785-650-2368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS916573224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant