Provider Demographics
NPI:1285876201
Name:DIAZ, THERESA MARIE (OTR/L)
Entity type:Individual
Prefix:MISS
First Name:THERESA
Middle Name:MARIE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5820 FLINTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1883
Mailing Address - Country:US
Mailing Address - Phone:719-599-7328
Mailing Address - Fax:719-264-0227
Practice Address - Street 1:5820 FLINTRIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918
Practice Address - Country:US
Practice Address - Phone:719-599-7328
Practice Address - Fax:719-264-0227
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-06
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1699225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1699OtherSTATE OF COLORADO LICENSURE