Provider Demographics
NPI:1518159409
Name:GULTOM, ANDREW MELBON (COTA)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:MELBON
Last Name:GULTOM
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:1065 DRIFTWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-6321
Mailing Address - Country:US
Mailing Address - Phone:909-856-6625
Mailing Address - Fax:877-799-9128
Practice Address - Street 1:1065 DRIFTWOOD CIR
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-6321
Practice Address - Country:US
Practice Address - Phone:909-856-6625
Practice Address - Fax:877-799-9128
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1013224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant