Provider Demographics
NPI:1508993999
Name:MARTIN, DIANA MARY (MA OTR)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:MARY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:212 N IRENA AVE
Mailing Address - Street 2:UNIT B
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3258
Mailing Address - Country:US
Mailing Address - Phone:310-316-3261
Mailing Address - Fax:
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:MAILSTOP #56
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-669-2118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA971225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist