Provider Demographics
NPI:1194083196
Name:YAKUTILOVA, DIANA (OT)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:YAKUTILOVA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6135 98TH ST
Mailing Address - Street 2:APT 3B
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1426
Mailing Address - Country:US
Mailing Address - Phone:718-406-7820
Mailing Address - Fax:
Practice Address - Street 1:2075 E 68TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-6009
Practice Address - Country:US
Practice Address - Phone:718-968-7866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP82982225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist