Provider Demographics
NPI:1972192110
Name:PHILLIPS, DIANA L (LMT)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SYCAMORE LN APT 102
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:OH
Mailing Address - Zip Code:44202-7649
Mailing Address - Country:US
Mailing Address - Phone:330-671-6101
Mailing Address - Fax:
Practice Address - Street 1:8900 DARROW RD STE H102
Practice Address - Street 2:
Practice Address - City:TWINSBURG
Practice Address - State:OH
Practice Address - Zip Code:44087-6801
Practice Address - Country:US
Practice Address - Phone:330-671-6101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.024752225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty