Provider Demographics
NPI:1609166578
Name:DIAZ, CRYSTAL LYNN (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:LYNN
Last Name:DIAZ
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 BEACH 102ND STREET
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694
Mailing Address - Country:US
Mailing Address - Phone:570-856-5953
Mailing Address - Fax:
Practice Address - Street 1:60 E 104TH ST
Practice Address - Street 2:3C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-4524
Practice Address - Country:US
Practice Address - Phone:212-933-0820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007835-1174400000X
NY021885225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist