Healthcare Provider Details

I. General information

NPI: 1104733401
Provider Name (Legal Business Name): THERESA LYNN DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2409 PINE ORCHARD DR
WATERFORD MI
48329-3970
US

IV. Provider business mailing address

2409 PINE ORCHARD DR
WATERFORD MI
48329-3970
US

V. Phone/Fax

Practice location:
  • Phone: 248-605-5921
  • Fax:
Mailing address:
  • Phone: 248-605-5921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202005643
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: