Provider Demographics
NPI:1982971537
Name:DONOGHUE, DIANE MARIE (LICENSED)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:DONOGHUE
Suffix:
Gender:F
Credentials:LICENSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 PROSPERITY CHURCH RD
Mailing Address - Street 2:SHADS LANDING
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269
Mailing Address - Country:US
Mailing Address - Phone:704-548-9111
Mailing Address - Fax:704-548-9191
Practice Address - Street 1:5101 PROSPERITY CHURCH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-8732
Practice Address - Country:US
Practice Address - Phone:704-548-9111
Practice Address - Fax:704-548-9191
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC752225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant