Provider Demographics
NPI:1114938644
Name:KLEIST, DIANE MCDERMOTT (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MCDERMOTT
Last Name:KLEIST
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 1:152 COURT ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-4416
Mailing Address - Country:US
Mailing Address - Phone:603-427-5370
Mailing Address - Fax:603-427-5370
Practice Address - Street 1:152 COURT ST
Practice Address - Street 2:SUITE 4
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-4416
Practice Address - Country:US
Practice Address - Phone:603-427-5370
Practice Address - Fax:603-427-5370
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0920225100000X
MEPT379225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3533245OtherAETNA
NH0806164Y0NH02OtherANTHEM BC/BS
NH30392870Medicaid
NH2198450OtherFIRST HEALTH NETWORK
NH5515310OtherCCN
NH5515310OtherCCN
NH4303232Medicare UPIN