Provider Demographics
NPI:1710583398
Name:HERRERA GUTIERREZ, DIEGO FERNANDO (OTR/L)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:FERNANDO
Last Name:HERRERA GUTIERREZ
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 SALEM SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-1594
Mailing Address - Country:US
Mailing Address - Phone:743-201-8938
Mailing Address - Fax:
Practice Address - Street 1:6000 MEADOWBROOK MALL CT STE 22
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8775
Practice Address - Country:US
Practice Address - Phone:336-778-0292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13333225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Single Specialty