Provider Demographics
NPI:1609919489
Name:WIERENGA, LAUREEN ANNE (CAADE)
Entity Type:Individual
Prefix:MS
First Name:LAUREEN
Middle Name:ANNE
Last Name:WIERENGA
Suffix:
Gender:F
Credentials:CAADE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14660 OXNARD ST
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-3119
Mailing Address - Country:US
Mailing Address - Phone:818-901-4836
Mailing Address - Fax:818-376-0044
Practice Address - Street 1:14660 OXNARD ST.
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411
Practice Address - Country:US
Practice Address - Phone:818-901-4836
Practice Address - Fax:818-376-0044
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA970217225400000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health