Healthcare Provider Details

I. General information

NPI: 1043408933
Provider Name (Legal Business Name): DIANN MICHELE WINGERT LCSW, BCD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 02/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E DEL MAR BLVD SUITE 200
PASADENA CA
91105-2544
US

IV. Provider business mailing address

200 E DEL MAR BLVD SUITE 200
PASADENA CA
91105-2544
US

V. Phone/Fax

Practice location:
  • Phone: 818-679-4879
  • Fax:
Mailing address:
  • Phone: 818-679-4879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 18694
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: