Healthcare Provider Details

I. General information

NPI: 1578533998
Provider Name (Legal Business Name): DIANA MARIE WIECKOWICZ MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: DIANA MARIE WICKOWICZ MFT

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 LOS GATOS SARATOGA RD
LOS GATOS CA
95030-5327
US

IV. Provider business mailing address

300 APPLE LN
APTOS CA
95003-9623
US

V. Phone/Fax

Practice location:
  • Phone: 408-356-8992
  • Fax: 831-684-2549
Mailing address:
  • Phone: 831-818-0595
  • Fax: 831-684-2549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number30273
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: