Provider Demographics
NPI:1578823266
Name:WILLIAMS, DIANA GAY (COTA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:GAY
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20104 NYS ROUTE 3
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5560
Mailing Address - Country:US
Mailing Address - Phone:315-779-7159
Mailing Address - Fax:315-779-7109
Practice Address - Street 1:20104 NYS ROUTE 3
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5560
Practice Address - Country:US
Practice Address - Phone:315-779-7159
Practice Address - Fax:315-779-7109
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002104224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant