Provider Demographics
NPI:1336509991
Name:DIETRICH-WAGER, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DIETRICH-WAGER
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 1:4905 CHAUCER AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-1106
Mailing Address - Country:US
Mailing Address - Phone:619-861-4085
Mailing Address - Fax:
Practice Address - Street 1:1201 34TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2416
Practice Address - Country:US
Practice Address - Phone:619-232-2946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA832224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant