Provider Demographics
NPI:1720239486
Name:WELLER, DEBORAH
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:WELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1977 N GAREY AVE
Mailing Address - Street 2:STE 6
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2774
Mailing Address - Country:US
Mailing Address - Phone:909-623-6651
Mailing Address - Fax:909-623-0455
Practice Address - Street 1:11927 ELLIOTT AVE
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91732-3740
Practice Address - Country:US
Practice Address - Phone:626-350-0805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0001588OtherLACDMH STAFF CODE