Provider Demographics
NPI:1245717495
Name:MORCILLA, DIANA ROSE (OTR/L)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:ROSE
Last Name:MORCILLA
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 1:2259 33RD ST APT 1
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2424
Mailing Address - Country:US
Mailing Address - Phone:929-421-2147
Mailing Address - Fax:
Practice Address - Street 1:2259 33RD ST APT 1
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-2424
Practice Address - Country:US
Practice Address - Phone:929-421-2147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009797224Z00000X
NY027211225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY102790954Medicaid