Provider Demographics
NPI:1841888567
Name:ENRIQUEZ, DIORELLA MARIEL G
Entity type:Individual
Prefix:
First Name:DIORELLA MARIEL
Middle Name:G
Last Name:ENRIQUEZ
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 1:2016 ALSCOT AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-3806
Mailing Address - Country:US
Mailing Address - Phone:818-687-3187
Mailing Address - Fax:
Practice Address - Street 1:250 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-2456
Practice Address - Country:US
Practice Address - Phone:805-494-1233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49705225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant