Provider Demographics
NPI:1720152903
Name:KISZKA, DIANE BOUTET (PT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:BOUTET
Last Name:KISZKA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 BRIDLE PATH LN
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-1570
Mailing Address - Country:US
Mailing Address - Phone:978-685-3154
Mailing Address - Fax:
Practice Address - Street 1:26 BRIDLE PATH LN
Practice Address - Street 2:
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-1570
Practice Address - Country:US
Practice Address - Phone:978-685-3154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3141225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist