Provider Demographics
NPI:1992823520
Name:DIAZ, EDWIN MANUEL (OTRL)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:MANUEL
Last Name:DIAZ
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 N BICYCLE PATH
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2287
Mailing Address - Country:US
Mailing Address - Phone:631-846-9137
Mailing Address - Fax:
Practice Address - Street 1:140 N BICYCLE PATH
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2287
Practice Address - Country:US
Practice Address - Phone:631-846-9137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0095911225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist