Provider Demographics
NPI:1205590825
Name:REISERT, DIANA ELIZABETH
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:ELIZABETH
Last Name:REISERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16652 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-4004
Mailing Address - Country:US
Mailing Address - Phone:347-804-4693
Mailing Address - Fax:
Practice Address - Street 1:2579 OCEAN AVE FL 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4552
Practice Address - Country:US
Practice Address - Phone:646-780-0926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2022-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047949225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist