Provider Demographics
NPI:1063657120
Name:MCCORMACK, DIANE JEAN (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:JEAN
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:JEAN
Other - Last Name:BERG MCCORMACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTR/L
Mailing Address - Street 1:P.O. BOX 1382
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56502
Mailing Address - Country:US
Mailing Address - Phone:218-234-1302
Mailing Address - Fax:
Practice Address - Street 1:15840 LONG LAKE ROAD
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501
Practice Address - Country:US
Practice Address - Phone:218-847-5071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100296225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics