Provider Demographics
NPI:1134287063
Name:MODICA, DIANE (MS OTR CHT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:MODICA
Suffix:
Gender:F
Credentials:MS OTR CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 WHITFORD AVENUE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110
Mailing Address - Country:US
Mailing Address - Phone:973-542-1450
Mailing Address - Fax:
Practice Address - Street 1:1373 BROAD STREET
Practice Address - Street 2:SUITE 302
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013
Practice Address - Country:US
Practice Address - Phone:973-773-4263
Practice Address - Fax:973-773-4336
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00190911225X00000X
9209001871225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
068634TEQMedicare ID - Type Unspecified