Provider Demographics
NPI:1154542934
Name:KOMITZKY, DIANE S (OTRL)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:S
Last Name:KOMITZKY
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 COVENTRY RD
Mailing Address - Street 2:
Mailing Address - City:CHELTENHAM
Mailing Address - State:PA
Mailing Address - Zip Code:19012-1003
Mailing Address - Country:US
Mailing Address - Phone:215-635-9583
Mailing Address - Fax:
Practice Address - Street 1:551 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:HAVERFORD
Practice Address - State:PA
Practice Address - Zip Code:19041-1419
Practice Address - Country:US
Practice Address - Phone:610-525-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC003761L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist