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NPI Code Detail

MEDICARE: MRS. DIANE MARIE CROCKETT PT

MEDICARE: MRS. DIANE MARIE CROCKETT PT
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
1225100000XPhysical TherapistPT005002OH

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1OH1171721OTHEROHOHIO DEPT. OF EDUCATION
211508426OTHEROHCAQH

General Provider Information

NPI Number : 1063592806
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. DIANE MARIE CROCKETT PT
Provider Business Mailing Address
First Line : 5000 ROCKSIDE RD STE 500
Second Line :
City : INDEPENDENCE
State : OH
Zip : 44131-2178
Country : US
Telephone Number : 216-489-2846
Fax Number : 216-901-2803
Provider Business Practice Location Address
First Line : 11136 RAVENNA RD
Second Line :
City : TWINSBURG
State : OH
Zip : 44087-1022
Country : US
Telephone Number : 330-486-2000
Fax Number : 330-425-7216
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/16/2006
Last Update Date : 11/06/2019

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