Provider Demographics
NPI:1669121216
Name:LOBUSTA, DIADHEN BERNARDO (PT, DPT)
Entity type:Individual
Prefix:MISS
First Name:DIADHEN
Middle Name:BERNARDO
Last Name:LOBUSTA
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 1:105 CASTLE DR APT 74
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-6555
Mailing Address - Country:US
Mailing Address - Phone:256-585-8152
Mailing Address - Fax:
Practice Address - Street 1:1736 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3040
Practice Address - Country:US
Practice Address - Phone:334-712-6333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26564225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist