Provider Demographics
NPI:1730293267
Name:GUSTITUS, DARREN (OT)
Entity Type:Individual
Prefix:
First Name:DARREN
Middle Name:
Last Name:GUSTITUS
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26750 PROVIDENCE PARKWAY
Mailing Address - Street 2:AUITE 220
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374
Mailing Address - Country:US
Mailing Address - Phone:248-596-0412
Mailing Address - Fax:248-596-0418
Practice Address - Street 1:26750 PROVIDENCE PAKRWAY
Practice Address - Street 2:SUITE 220
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374
Practice Address - Country:US
Practice Address - Phone:248-596-0412
Practice Address - Fax:248-596-0418
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004144225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDC8504Medicare PIN
MI5812140001Medicare NSC
MIN95100003Medicare PIN
MI0N95100Medicare PIN