Provider Demographics
NPI:1205343522
Name:CASTILLO, DIANE SANTIAGO (OTR/L)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:SANTIAGO
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 202
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90637-0202
Mailing Address - Country:US
Mailing Address - Phone:714-264-9804
Mailing Address - Fax:
Practice Address - Street 1:14809 STANTON AVE
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-4943
Practice Address - Country:US
Practice Address - Phone:714-264-9804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11613225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist