Provider Demographics
NPI:1629290317
Name:LEE, DIANE (OTA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ALTA
Mailing Address - State:IA
Mailing Address - Zip Code:51002-1453
Mailing Address - Country:US
Mailing Address - Phone:712-200-3103
Mailing Address - Fax:
Practice Address - Street 1:506 E 4TH ST
Practice Address - Street 2:
Practice Address - City:SUTHERLAND
Practice Address - State:IA
Practice Address - Zip Code:51058-7668
Practice Address - Country:US
Practice Address - Phone:712-446-3857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01444224Z00000X
NE1134224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant