Provider Demographics
NPI:1689053779
Name:OWENS, GUSTA MICHELLE (ATC)
Entity Type:Individual
Prefix:MRS
First Name:GUSTA
Middle Name:MICHELLE
Last Name:OWENS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 S CREASY LN
Mailing Address - Street 2:STE 120
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-7438
Mailing Address - Country:US
Mailing Address - Phone:765-447-4165
Mailing Address - Fax:
Practice Address - Street 1:1411 S CREASY LN
Practice Address - Street 2:STE 120
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-7438
Practice Address - Country:US
Practice Address - Phone:765-447-4165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001127A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer