Provider Demographics
NPI:1376035089
Name:HAMILTON, DIANDRA
Entity Type:Individual
Prefix:
First Name:DIANDRA
Middle Name:
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANDRA
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MOTR/L
Mailing Address - Street 1:14201 W. SUNRISE BLVD.
Mailing Address - Street 2:UNIT 107
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323
Mailing Address - Country:US
Mailing Address - Phone:954-756-2818
Mailing Address - Fax:954-514-1126
Practice Address - Street 1:14201 W. SUNRISE BLVD.
Practice Address - Street 2:UNIT 107
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323
Practice Address - Country:US
Practice Address - Phone:954-756-2818
Practice Address - Fax:954-514-1126
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT18893225X00000X
FL18893225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100054600Medicaid