Provider Demographics
NPI:1447596671
Name:GILBERT, DIANE LAVERNE (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:LAVERNE
Last Name:GILBERT
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 RIDGEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-3340
Mailing Address - Country:US
Mailing Address - Phone:708-548-7405
Mailing Address - Fax:
Practice Address - Street 1:6700 S KEATING AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5660
Practice Address - Country:US
Practice Address - Phone:773-284-5637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-16
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.001903172V00000X
IL057001903224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No172V00000XOther Service ProvidersCommunity Health Worker