Provider Demographics
NPI:1356824916
Name:SUPAK, DIANE MILLER
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MILLER
Last Name:SUPAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 FM 2503
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78940-5101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:457 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945-1937
Practice Address - Country:US
Practice Address - Phone:979-968-5865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist