Provider Demographics
NPI:1972231074
Name:AMMEN, JUSTIN MATTHEW
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MATTHEW
Last Name:AMMEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9337 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-2028
Mailing Address - Country:US
Mailing Address - Phone:626-475-8680
Mailing Address - Fax:
Practice Address - Street 1:9337 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-2028
Practice Address - Country:US
Practice Address - Phone:626-475-8680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA462171224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant