Provider Demographics
NPI:1881214955
Name:DIENZO, WELDON CHARLES (COTA/L)
Entity Type:Individual
Prefix:
First Name:WELDON
Middle Name:CHARLES
Last Name:DIENZO
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3470 E LA JARA ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-3847
Mailing Address - Country:US
Mailing Address - Phone:562-688-8305
Mailing Address - Fax:
Practice Address - Street 1:12627 STUDEBAKER RD
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-2518
Practice Address - Country:US
Practice Address - Phone:562-868-4767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-19
Last Update Date:2020-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1666224Z00000X, 224ZE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No224ZE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantEnvironmental Modification