Provider Demographics
NPI:1457742579
Name:DIEHM, GARY (ATC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:DIEHM
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 TAFT BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2036
Mailing Address - Country:US
Mailing Address - Phone:940-397-6236
Mailing Address - Fax:940-397-6878
Practice Address - Street 1:3410 TAFT BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2036
Practice Address - Country:US
Practice Address - Phone:940-397-6236
Practice Address - Fax:940-397-6878
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT25702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer