Provider Demographics
NPI:1790096139
Name:COSTULAS, DIANE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:COSTULAS
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10517 SANTA LAGUNA DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-1208
Mailing Address - Country:US
Mailing Address - Phone:570-295-3579
Mailing Address - Fax:
Practice Address - Street 1:7301 W PALMETTO PARK RD STE 106B
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3455
Practice Address - Country:US
Practice Address - Phone:561-571-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC010843225X00000X
FLOT21478225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist