Basic Information
| Provider Information | |||||||||
| NPI: | 1386974822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TUSICK | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | KATHLEEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | COTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GIBSON | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | KATHLEEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 401 LOCUST ST | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | CORAOPOLIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151083954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122990704 | ||||||||
| FaxNumber: | 4122992823 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 LOCUST ST | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | CORAOPOLIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151083954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122990704 | ||||||||
| FaxNumber: | 4122992823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2010 | ||||||||
| LastUpdateDate: | 01/06/2010 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | TOP008118 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.