Provider Demographics
NPI:1083025506
Name:MACASAET, DIANA (PT)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MACASAET
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 HANOVER LN
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1811 HANOVER LN
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-1923
Practice Address - Country:US
Practice Address - Phone:708-629-9724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.020393225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist