Provider Demographics
NPI:1013428234
Name:SWEENEY, DIANE S (PT)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:S
Last Name:SWEENEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:S
Other - Last Name:HAUDRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:916 TALON DR STE 102
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1848
Mailing Address - Country:US
Mailing Address - Phone:618-628-8211
Mailing Address - Fax:618-628-0883
Practice Address - Street 1:12 WOLF CREEK DR STE 200C
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2314
Practice Address - Country:US
Practice Address - Phone:618-628-8211
Practice Address - Fax:618-628-0883
Is Sole Proprietor?:No
Enumeration Date:2017-10-15
Last Update Date:2017-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070006227225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist