Provider Demographics
NPI:1629132147
Name:WEST, DIANE M (LPT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:WEST
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 HULEN ST
Mailing Address - Street 2:HTN, CLIENT ACCOUNTING
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-7277
Mailing Address - Country:US
Mailing Address - Phone:817-569-4395
Mailing Address - Fax:817-569-4517
Practice Address - Street 1:3840 HULEN ST
Practice Address - Street 2:HTN, CLIENT ACCOUNTING
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7277
Practice Address - Country:US
Practice Address - Phone:817-569-4395
Practice Address - Fax:817-569-4517
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1044246225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142890601Medicaid
TX142890602Medicaid
TX86832TOtherBCBS