Provider Demographics
NPI:1750852281
Name:DIAZ, MARTHA (PTA)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:DIAZ
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 1:311 20TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-6441
Mailing Address - Country:US
Mailing Address - Phone:347-216-1856
Mailing Address - Fax:
Practice Address - Street 1:311 20TH ST APT 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-6441
Practice Address - Country:US
Practice Address - Phone:347-216-1856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007532225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty