Healthcare Provider Details

I. General information

NPI: 1265609366
Provider Name (Legal Business Name): DIANE M LUCA PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 LINCOLN ST
NEEDHAM MA
02492-2914
US

IV. Provider business mailing address

19 WENTWORTH RD
CANTON MA
02021-1646
US

V. Phone/Fax

Practice location:
  • Phone: 781-449-4040
  • Fax:
Mailing address:
  • Phone: 781-828-3370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3481
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: