Basic Information
| Provider Information | |||||||||
| NPI: | 1881214955 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIENZO | ||||||||
| FirstName: | WELDON | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3470 E LA JARA ST | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908053847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626888305 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12627 STUDEBAKER RD | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906502518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628684767 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2020 | ||||||||
| LastUpdateDate: | 04/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 1666 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224ZE0001X | 1666 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | Environmental Modification |
No ID Information.