Provider Demographics
NPI:1528621935
Name:SRAL, DIANE (COTA)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:SRAL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2126 SERENITY LN
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-7017
Mailing Address - Country:US
Mailing Address - Phone:815-334-7856
Mailing Address - Fax:
Practice Address - Street 1:2126 SERENITY LN
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-7017
Practice Address - Country:US
Practice Address - Phone:815-334-7856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057005166224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant