Provider Demographics
NPI:1043578412
Name:CHANG, DIANA S (OTR/L)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:S
Last Name:CHANG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 DONNIE AVE
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76541-8918
Mailing Address - Country:US
Mailing Address - Phone:254-634-8505
Mailing Address - Fax:254-221-7710
Practice Address - Street 1:1102 WINKLER AVE
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-6249
Practice Address - Country:US
Practice Address - Phone:254-634-8505
Practice Address - Fax:254-221-7710
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005365225X00000X
NY017570225X00000X
TX117102225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist