Provider Demographics
NPI:1013073196
Name:DIMOCK, ANN WAGNER (MFT)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:WAGNER
Last Name:DIMOCK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280542
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91328-0542
Mailing Address - Country:US
Mailing Address - Phone:818-349-1401
Mailing Address - Fax:818-988-5474
Practice Address - Street 1:9659 BALBOA BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-1902
Practice Address - Country:US
Practice Address - Phone:818-349-1401
Practice Address - Fax:818-988-5474
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC23900106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist