Provider Demographics
NPI:1093023202
Name:DIMMITT, LAUREN P
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:P
Last Name:DIMMITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4176 COLE CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-1112
Mailing Address - Country:US
Mailing Address - Phone:619-261-3798
Mailing Address - Fax:
Practice Address - Street 1:5075 SHOREHAM PL STE 115
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-5927
Practice Address - Country:US
Practice Address - Phone:858-272-2662
Practice Address - Fax:858-272-2661
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 106E00000X, 106S00000X
CA1-23-69834103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician