Provider Demographics
NPI:1295592202
Name:INNOCENT, DIANA MARY (PT, DPT)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:MARY
Last Name:INNOCENT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HERITAGE DR APT B
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-5348
Mailing Address - Country:US
Mailing Address - Phone:845-596-8302
Mailing Address - Fax:
Practice Address - Street 1:80 ROUTE 6 UNIT 701702
Practice Address - Street 2:
Practice Address - City:BALDWIN PLACE
Practice Address - State:NY
Practice Address - Zip Code:10505-1026
Practice Address - Country:US
Practice Address - Phone:845-875-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-05
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051531225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist