Healthcare Provider Details

I. General information

NPI: 1124157565
Provider Name (Legal Business Name): PETER DIMANNO PETER DIMANNO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: PETER DIMANNO PETER DIMANNO LCSW

II. Dates (important events)

Enumeration Date: 03/03/2007
Last Update Date: 02/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 N IMPERIAL AVE SUITE 205
EL CENTRO CA
92243-6301
US

IV. Provider business mailing address

1503 N IMPERIAL AVE SUITE 205
EL CENTRO CA
92243-6301
US

V. Phone/Fax

Practice location:
  • Phone: 760-352-4773
  • Fax: 760-352-4747
Mailing address:
  • Phone: 760-352-4773
  • Fax: 760-352-4747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS10084
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: