MEDICARE: DIANE A VESTAL OTA/L

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
1	224Z00000X	Occupational Therapy Assistant	A00725	MD

General Provider Information

NPI Number	:	1417312489
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE A VESTAL OTA/L

Provider Business Mailing Address
First Line	:	311 TAPLOW RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21212-3540
Country	:	US
Telephone Number	:	410-530-1645
Fax Number	:

Provider Business Practice Location Address
First Line	:	1320 WINDLASS DR
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21220-4100
Country	:	US
Telephone Number	:	410-918-2139
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/17/2015
Last Update Date	:	12/17/2015

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Directions to “ DIANE A VESTAL OTA/L” Practice Location

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