1609166578 NPI number — MS. CRYSTAL LYNN DIAZ OTR/L

Table of content: MS. CRYSTAL LYNN DIAZ OTR/L (NPI 1609166578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609166578 NPI number — MS. CRYSTAL LYNN DIAZ OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIAZ
Provider First Name:
CRYSTAL
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609166578
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
340 BEACH 102ND STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKAWAY PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11694
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-856-5953
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 E 104TH ST
Provider Second Line Business Practice Location Address:
3C
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10029-4524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-933-0820
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  007835-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: 021885 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)