Provider Demographics
NPI:1750593224
Name:DIETZ, PEARL
Entity type:Individual
Prefix:
First Name:PEARL
Middle Name:
Last Name:DIETZ
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 1:1844 MIDVALE AVE # NO.5
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-4560
Mailing Address - Country:US
Mailing Address - Phone:310-475-3775
Mailing Address - Fax:
Practice Address - Street 1:5120 W GOLDLEAF CIR
Practice Address - Street 2:SUITE 400
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90056-1292
Practice Address - Country:US
Practice Address - Phone:310-574-3733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 56172251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics