Provider Demographics
NPI:1710462379
Name:THOMAS, DIANE YOUNG (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:YOUNG
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 WOODFORD DR
Mailing Address - Street 2:
Mailing Address - City:MORAGA
Mailing Address - State:CA
Mailing Address - Zip Code:94556-2429
Mailing Address - Country:US
Mailing Address - Phone:925-408-0402
Mailing Address - Fax:
Practice Address - Street 1:3468 MT DIABLO BLVD STE B110
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-7105
Practice Address - Country:US
Practice Address - Phone:925-408-0402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-30
Last Update Date:2018-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20290225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist