Provider Demographics
NPI:1255495297
Name:BIENKOWSKI, EDMUND S
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:S
Last Name:BIENKOWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31460 CONGRESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-6986
Mailing Address - Country:US
Mailing Address - Phone:562-864-7821
Mailing Address - Fax:562-864-7864
Practice Address - Street 1:12440 FIRESTONE BLVD STE 3020
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-9328
Practice Address - Country:US
Practice Address - Phone:562-864-7821
Practice Address - Fax:562-864-7864
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12572103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical