Provider Demographics
NPI:1154899862
Name:STOLL, DIANA DOROTHY (MSOT, OTR/L)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:DOROTHY
Last Name:STOLL
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 NATHAN DR
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-1317
Mailing Address - Country:US
Mailing Address - Phone:631-704-7079
Mailing Address - Fax:
Practice Address - Street 1:75 NATHAN DR
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-1317
Practice Address - Country:US
Practice Address - Phone:631-704-7079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023106225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist