Provider Demographics
NPI:1104367606
Name:DEVITO-STEWART, DIANA (LMT)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:DEVITO-STEWART
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:OM-SHANTI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:226 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-9796
Mailing Address - Country:US
Mailing Address - Phone:516-605-4868
Mailing Address - Fax:
Practice Address - Street 1:6 S JERSEY AVE
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2021
Practice Address - Country:US
Practice Address - Phone:516-605-4868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027428174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist