Provider Demographics
NPI:1295190171
Name:ROSALES-HERNANDEZ, DIANA (PT)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:ROSALES-HERNANDEZ
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 1:4425 S MOPAC EXPY #2, SUITE 102
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-6700
Mailing Address - Country:US
Mailing Address - Phone:512-407-8766
Mailing Address - Fax:
Practice Address - Street 1:4425 S MOPAC EXPY #2, SUITE 102
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-6710
Practice Address - Country:US
Practice Address - Phone:512-407-8766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1175840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2251000000XOtherTAXONOMY CODE
TX1175840OtherPT LICENSE#