Provider Demographics
NPI:1154541894
Name:DIEFFENBACH, VIRGINIA R (OTR L)
Entity type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:R
Last Name:DIEFFENBACH
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7911 W 93RD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212
Mailing Address - Country:US
Mailing Address - Phone:913-341-9533
Mailing Address - Fax:913-262-8070
Practice Address - Street 1:5350 W 61ST PLACE
Practice Address - Street 2:MISSION SPRINGS ALF
Practice Address - City:MISSION
Practice Address - State:KS
Practice Address - Zip Code:66205
Practice Address - Country:US
Practice Address - Phone:913-831-7700
Practice Address - Fax:913-831-7733
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1700068225X00000X
MO2005001474225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS37219016OtherBCBS
MO37219016OtherBCBS