Provider Demographics
NPI:1578533998
Name:WIECKOWICZ, DIANA MARIE (MFT)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:MARIE
Last Name:WIECKOWICZ
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:DIANA
Other - Middle Name:MARIE
Other - Last Name:WICKOWICZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:300 APPLE LN
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-9623
Mailing Address - Country:US
Mailing Address - Phone:831-818-0595
Mailing Address - Fax:831-684-2549
Practice Address - Street 1:301 LOS GATOS SARATOGA RD
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-5327
Practice Address - Country:US
Practice Address - Phone:408-356-8992
Practice Address - Fax:831-684-2549
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30273106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist