Provider Demographics
NPI:1063592806
Name:CROCKETT, DIANE MARIE (PT)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARIE
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 ROCKSIDE RD STE 500
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2178
Mailing Address - Country:US
Mailing Address - Phone:216-489-2846
Mailing Address - Fax:216-901-2803
Practice Address - Street 1:11136 RAVENNA RD
Practice Address - Street 2:
Practice Address - City:TWINSBURG
Practice Address - State:OH
Practice Address - Zip Code:44087-1022
Practice Address - Country:US
Practice Address - Phone:330-486-2000
Practice Address - Fax:330-425-7216
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT005002225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOH1171721OtherOHIO DEPT. OF EDUCATION
OH11508426OtherCAQH