Provider Demographics
NPI:1063003531
Name:CRADDOCK, DIANE MARIE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARIE
Last Name:CRADDOCK
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 1:111 FAIRGROUND RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26351-1388
Mailing Address - Country:US
Mailing Address - Phone:304-462-5718
Mailing Address - Fax:
Practice Address - Street 1:111 FAIRGROUND RD
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:WV
Practice Address - Zip Code:26351-1388
Practice Address - Country:US
Practice Address - Phone:304-462-5718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC2094224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant