Provider Demographics
NPI:1114103827
Name:ANDERSON, DIANE LEIGH (PTA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LEIGH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 STRAWBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:PA
Mailing Address - Zip Code:16146-3235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:161 STRAWBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SHARON
Practice Address - State:PA
Practice Address - Zip Code:16146-3235
Practice Address - Country:US
Practice Address - Phone:724-983-1014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH05210172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker