Provider Demographics
NPI:1720314081
Name:DIAZ, DANIEL OMAR (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:OMAR
Last Name:DIAZ
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7753 VAN BUREN ST
Mailing Address - Street 2:#317
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-1887
Mailing Address - Country:US
Mailing Address - Phone:708-351-3409
Mailing Address - Fax:
Practice Address - Street 1:3703 W LAKE AVE
Practice Address - Street 2:200
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1223
Practice Address - Country:US
Practice Address - Phone:847-998-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008786225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist