Provider Demographics
NPI:1114385028
Name:AGOSTO, DIANNE (OTR/L)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:AGOSTO
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 1:321 EARLMONT PL
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33896-3090
Mailing Address - Country:US
Mailing Address - Phone:787-568-7283
Mailing Address - Fax:
Practice Address - Street 1:6-25 CALLE 7
Practice Address - Street 2:URB. SANTA ROSA
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959-6637
Practice Address - Country:US
Practice Address - Phone:787-568-7283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1088225X00000X
FL18759225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist