Provider Demographics
NPI:1245388966
Name:BAL, DIANA C (MHSOT)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:C
Last Name:BAL
Suffix:
Gender:F
Credentials:MHSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CHURCHILL CT
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-3454
Mailing Address - Country:US
Mailing Address - Phone:843-821-9175
Mailing Address - Fax:843-821-9170
Practice Address - Street 1:109 CHURCHILL CT
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-3454
Practice Address - Country:US
Practice Address - Phone:843-821-9175
Practice Address - Fax:843-821-9170
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC704225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH0663Medicaid