Provider Demographics
NPI:1568476877
Name:DIVERGILIO-ANTONETTE, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:DIVERGILIO-ANTONETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 DART ST
Mailing Address - Street 2:
Mailing Address - City:EAST ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11518-1730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:380 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-1845
Practice Address - Country:US
Practice Address - Phone:516-378-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0009319225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00009319Medicaid