=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134321821
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANE LYNNE FROEHLICH ATC, LAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2007
-----------------------------------------------------
Last Update Date | 01/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 155 DUNDERBERG RD
-----------------------------------------------------
City | CENTRAL VALLEY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10917-3507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-460-7647
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 326 BEAVER DAM RD
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12549-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 458-522-4300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 25MT00126500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 001203-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------