MEDICARE: MS. CRYSTAL LYNN DIAZ OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	007835-1	NY
2	225X00000X	Occupational Therapist	021885	NY

General Provider Information

NPI Number	:	1609166578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CRYSTAL LYNN DIAZ OTR/L

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

Provider Business Practice Location Address
First Line	:	60 E 104TH ST
Second Line	:	3C
City	:	NEW YORK
State	:	NY
Zip	:	10029-4524
Country	:	US
Telephone Number	:	212-933-0820
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2011
Last Update Date	:	09/13/2017

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