Provider Demographics
NPI:1043292527
Name:GOTEBIOWSKI, DIANE LYNN (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LYNN
Last Name:GOTEBIOWSKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:LYNN
Other - Last Name:MICKLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 311
Mailing Address - Street 2:
Mailing Address - City:CATSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12414-0311
Mailing Address - Country:US
Mailing Address - Phone:518-943-9188
Mailing Address - Fax:518-943-6513
Practice Address - Street 1:7987 US HIGHWAY 9W
Practice Address - Street 2:
Practice Address - City:CATSKILL
Practice Address - State:NY
Practice Address - Zip Code:12414-5036
Practice Address - Country:US
Practice Address - Phone:518-943-9188
Practice Address - Fax:518-943-6513
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005961225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ55011Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER