Provider Demographics
NPI:1811471170
Name:WREN, DOREEN (LAC, LMT)
Entity type:Individual
Prefix:
First Name:DOREEN
Middle Name:
Last Name:WREN
Suffix:
Gender:F
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6274 LAKE LOMOND DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-3030
Mailing Address - Country:US
Mailing Address - Phone:619-488-7990
Mailing Address - Fax:
Practice Address - Street 1:6274 LAKE LOMOND DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92119-3030
Practice Address - Country:US
Practice Address - Phone:619-488-7990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39584225700000X
CA18129171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist