Provider Demographics
NPI:1376732552
Name:DECRISTOFORO, DIANE (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:DECRISTOFORO
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 1:2050 BROOK MAR CT
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-3701
Mailing Address - Country:US
Mailing Address - Phone:206-992-7741
Mailing Address - Fax:
Practice Address - Street 1:4990 ROCKLIN RD
Practice Address - Street 2:SUITE #200
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-3336
Practice Address - Country:US
Practice Address - Phone:916-632-2273
Practice Address - Fax:916-632-2279
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30375225100000X
WA00007796225100000X
AK1678225100000X
CO9115225100000X
HI2539225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist