Provider Demographics
NPI:1770992505
Name:MCINTOSH, DIANNE B (PT)
Entity type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:B
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:DIANNE
Other - Middle Name:ELIZABETH
Other - Last Name:BOLTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845
Mailing Address - Country:US
Mailing Address - Phone:260-266-4080
Mailing Address - Fax:260-266-4089
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR
Practice Address - Street 2:SUITE 050
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-266-4080
Practice Address - Fax:260-266-4089
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05000896A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist