Provider Demographics
NPI:1073659736
Name:PERITZ, DIANE (MA, OTR)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:PERITZ
Suffix:
Gender:F
Credentials:MA, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 HOLIDAY DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-2309
Mailing Address - Country:US
Mailing Address - Phone:516-637-5422
Mailing Address - Fax:516-921-3225
Practice Address - Street 1:112 HOLIDAY DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2309
Practice Address - Country:US
Practice Address - Phone:516-637-5422
Practice Address - Fax:516-921-3225
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008749174400000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist