Provider Demographics
NPI:1710691308
Name:VILLAR, DIANE MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:VILLAR
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9080 IRVINE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-4658
Mailing Address - Country:US
Mailing Address - Phone:949-540-5641
Mailing Address - Fax:
Practice Address - Street 1:2650 ELM AVE STE 209
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1600
Practice Address - Country:US
Practice Address - Phone:949-540-5641
Practice Address - Fax:562-600-0706
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6742225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant