Provider Demographics
NPI:1629577127
Name:CORONA, GUSTAVO JR (OTR/L)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:CORONA
Suffix:JR
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 SAWTELLE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6266
Mailing Address - Country:US
Mailing Address - Phone:626-589-0787
Mailing Address - Fax:
Practice Address - Street 1:245 W SIERRA MADRE BLVD # CA91024
Practice Address - Street 2:
Practice Address - City:SIERRA MADRE
Practice Address - State:CA
Practice Address - Zip Code:91024-2355
Practice Address - Country:US
Practice Address - Phone:626-355-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18371225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist