Basic Information
| Provider Information | |||||||||
| NPI: | 1609919489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIERENGA | ||||||||
| FirstName: | LAUREEN | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CAADE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14660 OXNARD ST | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914113119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189014836 | ||||||||
| FaxNumber: | 8183760044 | ||||||||
| Practice Location | |||||||||
| Address1: | 14660 OXNARD ST. | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189014836 | ||||||||
| FaxNumber: | 8183760044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 06/29/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | 970217 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.