Provider Demographics
NPI:1972858462
Name:LEDERER, LAUREN VICTORIA (DPT)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:VICTORIA
Last Name:LEDERER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 RUFFIN RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1802
Mailing Address - Country:US
Mailing Address - Phone:858-609-4185
Mailing Address - Fax:858-609-6651
Practice Address - Street 1:3939 RUFFIN RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1802
Practice Address - Country:US
Practice Address - Phone:858-609-4185
Practice Address - Fax:858-609-6651
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39159225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17215Medicare PIN
CAGK528ZMedicare PIN