Provider Demographics
NPI:1790031730
Name:PHIPPS, DIANE M (OT ASSISTANT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:PHIPPS
Suffix:
Gender:F
Credentials:OT ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-1902
Mailing Address - Country:US
Mailing Address - Phone:860-879-8066
Mailing Address - Fax:
Practice Address - Street 1:50 BEACH RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-1902
Practice Address - Country:US
Practice Address - Phone:860-879-8066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000452224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant