Healthcare Provider Details

I. General information

NPI: 1265346746
Provider Name (Legal Business Name): DOMINIC DIAZ OTD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19600 E 39TH ST S
INDEPENDENCE MO
64057-2301
US

IV. Provider business mailing address

4756 OAK ST APT 732
KANSAS CITY MO
64112-2235
US

V. Phone/Fax

Practice location:
  • Phone: 816-698-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2025007124
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: