Provider Demographics
NPI:1023091279
Name:BROCK, DIANE A (PTA)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:A
Last Name:BROCK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DTA
Mailing Address - Street 1:5214 S EAST ST
Mailing Address - Street 2:BLDG D STE 1
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-1917
Mailing Address - Country:US
Mailing Address - Phone:800-486-4449
Mailing Address - Fax:317-780-3745
Practice Address - Street 1:5214 S EAST ST
Practice Address - Street 2:HTS OUTPATIENT THERAPY SERVICES BLDG D STE 1
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1917
Practice Address - Country:US
Practice Address - Phone:800-486-4449
Practice Address - Fax:317-780-3745
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPTAA01579225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant