Provider Demographics
NPI:1972748275
Name:LOPEZ, DIWATA ENRIQUEZ (PT)
Entity Type:Individual
Prefix:
First Name:DIWATA
Middle Name:ENRIQUEZ
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DIWATA
Other - Middle Name:MACANDOG
Other - Last Name:ENRIQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5204 EDERIA WAY
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93313
Mailing Address - Country:US
Mailing Address - Phone:386-698-4720
Mailing Address - Fax:
Practice Address - Street 1:405 S SUMMIT ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:FL
Practice Address - Zip Code:32112-3047
Practice Address - Country:US
Practice Address - Phone:386-698-4720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-16
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20977225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist