Provider Demographics
NPI:1639142607
Name:GRAHAM, DIANNE HENSGENS (PT)
Entity Type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:HENSGENS
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:DIANNE
Other - Middle Name:
Other - Last Name:HENSGENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:7932 SUMMA AVE
Mailing Address - Street 2:SUITE B3
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3416
Mailing Address - Country:US
Mailing Address - Phone:225-769-9203
Mailing Address - Fax:
Practice Address - Street 1:7932 SUMMA AVE
Practice Address - Street 2:SUITE B3
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3416
Practice Address - Country:US
Practice Address - Phone:225-769-9203
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04454225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H391CP45Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER