Provider Demographics
NPI:1598984239
Name:WHITE, DIANE KAY (PT, MHS)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:KAY
Last Name:WHITE
Suffix:
Gender:F
Credentials:PT, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:HOPEDALE
Mailing Address - State:IL
Mailing Address - Zip Code:61747-9382
Mailing Address - Country:US
Mailing Address - Phone:309-449-6697
Mailing Address - Fax:
Practice Address - Street 1:6501 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2932
Practice Address - Country:US
Practice Address - Phone:309-692-8110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist