Provider Demographics
NPI:1184167397
Name:KUSTANTIN, LIZA
Entity type:Individual
Prefix:
First Name:LIZA
Middle Name:
Last Name:KUSTANTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 PALM AVE
Mailing Address - Street 2:402
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4066
Mailing Address - Country:US
Mailing Address - Phone:586-596-0452
Mailing Address - Fax:
Practice Address - Street 1:1515 N ALEXANDRIA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5203
Practice Address - Country:US
Practice Address - Phone:323-660-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT16697225X00000X
MI5201009655225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist