Provider Demographics
NPI:1669726543
Name:DIAZ, MALOU (PT)
Entity type:Individual
Prefix:
First Name:MALOU
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:LOURDES DIAZ
Other - Last Name:BUSTALINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:1738 165TH ST STE A
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-2821
Practice Address - Country:US
Practice Address - Phone:219-844-1782
Practice Address - Fax:219-844-1830
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007064A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN487210015Medicare PIN