Provider Demographics
NPI:1780735019
Name:BUCKLEY, DIANE L (COTA)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N2699 WILSON RD
Mailing Address - Street 2:
Mailing Address - City:POYNETTE
Mailing Address - State:WI
Mailing Address - Zip Code:53955-9564
Mailing Address - Country:US
Mailing Address - Phone:608-643-7263
Mailing Address - Fax:608-643-7667
Practice Address - Street 1:80 1ST ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-1550
Practice Address - Country:US
Practice Address - Phone:608-643-7263
Practice Address - Fax:608-643-7667
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI288027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant