Provider Demographics
NPI:1154866614
Name:FUERTES-DIEL, HAZEL (OTR/L)
Entity Type:Individual
Prefix:
First Name:HAZEL
Middle Name:
Last Name:FUERTES-DIEL
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 1:225 EINHAUS LN
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-1001
Mailing Address - Country:US
Mailing Address - Phone:217-220-9245
Mailing Address - Fax:
Practice Address - Street 1:225 EINHAUS LN
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-1001
Practice Address - Country:US
Practice Address - Phone:217-220-9245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008638225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056008638OtherILLINOIS BOARD OF OCCUPATIONAL THERAPY
IL056008638Medicare PIN