Provider Demographics
NPI:1811398126
Name:SHEAD, DIANE (PT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:SHEAD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 N WANDA RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-5343
Mailing Address - Country:US
Mailing Address - Phone:714-771-7047
Mailing Address - Fax:714-771-7051
Practice Address - Street 1:1421 N WANDA RD
Practice Address - Street 2:SUITE 110
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-5343
Practice Address - Country:US
Practice Address - Phone:714-771-7047
Practice Address - Fax:714-771-7051
Is Sole Proprietor?:No
Enumeration Date:2014-09-06
Last Update Date:2014-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT21771225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist