Provider Demographics
NPI:1609316751
Name:VISURI, DIANE (MSOT/L)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:VISURI
Suffix:
Gender:F
Credentials:MSOT/L
Other - Prefix:
Other - First Name:DINA
Other - Middle Name:
Other - Last Name:VISURI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSOT/L
Mailing Address - Street 1:S57W29687 SAYLESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-9793
Mailing Address - Country:US
Mailing Address - Phone:262-968-4477
Mailing Address - Fax:
Practice Address - Street 1:S57W29687 SAYLESVILLE RD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-9793
Practice Address - Country:US
Practice Address - Phone:262-968-4477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6026-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist