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General NPI Number Information
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NPI Number | 1558122994
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Entity Type | Individual
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Provider Name | JUSTINE MARIE PRIKOSOVICH PTA, CNS
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Gender | Female
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Dates
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Enumeration Date | 01/22/2024
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Last Update Date | 01/22/2024
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Provider Practice Location Address
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Address Line | 65250 SYCAMORE RD
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City | NORTH LIBERTY
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State | IN
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Zip | 46554-9086
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Country | US
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Telephone | 574-303-9292
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Fax | 574-381-5414
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Provider Business Mailing Address
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Address Line | PO BOX 233
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City | SOUTH BEND
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State | IN
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Zip | 46624-0233
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Country | US
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Telephone | 574-303-9292
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Fax | 574-381-5414
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 06005026A
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License Number State | IN
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