Provider Demographics
NPI:1184711970
Name:BRENNAN, DIANE L (PT,SCS)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:PT,SCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6199 TRANSIT RD
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-1024
Mailing Address - Country:US
Mailing Address - Phone:716-684-0649
Mailing Address - Fax:716-684-5107
Practice Address - Street 1:6199 TRANSIT RD
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-1024
Practice Address - Country:US
Practice Address - Phone:716-684-0649
Practice Address - Fax:716-268-4510
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009097-1225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9390415OtherINDEPENDENT HEALTH ID
NY00011185701OtherUNIVERA HEALTHCARE ID
NY000611533001OtherBLUE CROSS BLUE SHIELD ID
NY9390415OtherINDEPENDENT HEALTH ID
NY00011185701OtherUNIVERA HEALTHCARE ID