Provider Demographics
NPI:1467638239
Name:DECKER, DIADRA (LMT)
Entity Type:Individual
Prefix:MS
First Name:DIADRA
Middle Name:
Last Name:DECKER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 HAMLINE AVE N
Mailing Address - Street 2:SUITE 125
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-633-9106
Mailing Address - Fax:
Practice Address - Street 1:2233 HAMLINE AVE N
Practice Address - Street 2:SUITE 125
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:651-633-9106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist