Provider Demographics
NPI:1831340686
Name:REILLY, DIANE CAROL (PTA)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:CAROL
Last Name:REILLY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 ELIZABETH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LAURELDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19605-2259
Mailing Address - Country:US
Mailing Address - Phone:610-921-9292
Mailing Address - Fax:610-929-7985
Practice Address - Street 1:2125 ELIZABETH AVENUE
Practice Address - Street 2:
Practice Address - City:LAURELDALE
Practice Address - State:PA
Practice Address - Zip Code:19605-2259
Practice Address - Country:US
Practice Address - Phone:610-921-9292
Practice Address - Fax:610-929-7985
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE000709L225200000X
PATE1001104225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant