Provider Demographics
NPI:1285851550
Name:HRIVNAK, DIANE (OT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:HRIVNAK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1681
Mailing Address - Country:US
Mailing Address - Phone:248-349-9339
Mailing Address - Fax:248-349-9342
Practice Address - Street 1:215 E MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1681
Practice Address - Country:US
Practice Address - Phone:248-349-9339
Practice Address - Fax:248-349-9342
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003201224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H20094OtherBLUE CROSS BLUE SHIELD
MI0N58620OtherHAP
MI500573OtherPRIORITY HEALTH
MI16869OtherM-CARE
MIP00100555OtherMEDICARE RAILROAD
MI7543420OtherAETNA
MIN82620 002Medicare ID - Type UnspecifiedMEDICARE