Provider Demographics
NPI:1962469924
Name:MCCLUSKEY, DIANE CONSTANCE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:CONSTANCE
Last Name:MCCLUSKEY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:DIANE
Other - Middle Name:CONSTANCE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:3471 DEERFIELD LN NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1888
Mailing Address - Country:US
Mailing Address - Phone:770-792-5986
Mailing Address - Fax:678-290-0173
Practice Address - Street 1:3471 DEERFIELD LN NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-1888
Practice Address - Country:US
Practice Address - Phone:770-792-5986
Practice Address - Fax:678-290-0173
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002845225X00000X, 225XN1300X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Not Answered225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00907552AMedicaid
GA65BBBZJMedicare ID - Type Unspecified
GAP81001Medicare UPIN
GAGRP4915Medicare ID - Type UnspecifiedMEDICARE GROUP#
GA00907552AMedicaid