Provider Demographics
NPI:1124458666
Name:DUBAUSKAS, THERESA MARIE (COTA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:DUBAUSKAS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34237 TONQUISH TRL
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-7042
Mailing Address - Country:US
Mailing Address - Phone:734-728-8256
Mailing Address - Fax:
Practice Address - Street 1:22950 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-4696
Practice Address - Country:US
Practice Address - Phone:734-287-1230
Practice Address - Fax:734-287-8332
Is Sole Proprietor?:No
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202006807224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5202006807OtherOCCUPATIONAL THERAPY ASSISTANT REGISTRATION