Healthcare Provider Details

I. General information

NPI: 1942562764
Provider Name (Legal Business Name): KEVIN M DUSTIN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2265 MARKET STREET SUITE A
WARREN PA
16365-4682
US

IV. Provider business mailing address

110 PLEASANT DR
WARREN PA
16365-3348
US

V. Phone/Fax

Practice location:
  • Phone: 814-726-9050
  • Fax: 814-726-9629
Mailing address:
  • Phone: 570-878-9354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT022117
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: