Provider Demographics
NPI:1336368612
Name:DIEPENBROCK, MINDY (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MINDY
Middle Name:
Last Name:DIEPENBROCK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9862 SOLITARY PL
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-2517
Mailing Address - Country:US
Mailing Address - Phone:703-335-2339
Mailing Address - Fax:
Practice Address - Street 1:9862 SOLITARY PL
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136-2517
Practice Address - Country:US
Practice Address - Phone:703-335-2339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119002721225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics