Basic Information
Provider Information | |||||||||
NPI: | 1366952996 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BATTISTA | ||||||||
FirstName: | DIANE | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1377 MOTOR PKWY | ||||||||
Address2: | STE 307 | ||||||||
City: | ISLANDIA | ||||||||
State: | NY | ||||||||
PostalCode: | 117495258 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6315805200 | ||||||||
FaxNumber: | 6315805222 | ||||||||
Practice Location | |||||||||
Address1: | 360 N MAIN ST STE 9 | ||||||||
Address2: |   | ||||||||
City: | SOUTHINGTON | ||||||||
State: | CT | ||||||||
PostalCode: | 064892503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606217389 | ||||||||
FaxNumber: | 8606212586 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2017 | ||||||||
LastUpdateDate: | 08/23/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 010875 | CT | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 010875 | 01 | CT | CONNECTICUT LICENSE | OTHER |