Provider Demographics
NPI:1013391341
Name:GREGORY, DIANE (COTA/L)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:GREGORY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3985 MARIETTA DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-3214
Mailing Address - Country:US
Mailing Address - Phone:314-852-4565
Mailing Address - Fax:
Practice Address - Street 1:2000 BOARDWALK PLACE DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-3900
Practice Address - Country:US
Practice Address - Phone:618-292-2780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2015-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014024930224Z00000X
IL057.004125224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant