Provider Demographics
NPI:1104833250
Name:SU-ERICKSON, DIANA BEATRICE (OTR/L)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:BEATRICE
Last Name:SU-ERICKSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-0897
Mailing Address - Country:US
Mailing Address - Phone:909-796-2002
Mailing Address - Fax:909-799-9898
Practice Address - Street 1:11201 BENTON ST
Practice Address - Street 2:DEPT OF OCCUPATIONAL THERAPY 117B
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-1000
Practice Address - Country:US
Practice Address - Phone:909-825-7084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1982225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist