Provider Demographics
NPI:1013227560
Name:TAIT, DIANNA R (LMT, BCTMB)
Entity Type:Individual
Prefix:MS
First Name:DIANNA
Middle Name:R
Last Name:TAIT
Suffix:
Gender:F
Credentials:LMT, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1888 RIDGEVIEW
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-9490
Mailing Address - Country:US
Mailing Address - Phone:734-483-6994
Mailing Address - Fax:734-971-1360
Practice Address - Street 1:1888 RIDGEVIEW
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-9490
Practice Address - Country:US
Practice Address - Phone:734-483-6994
Practice Address - Fax:734-971-1360
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI530489-07225700000X
MI7501000286225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist