Provider Demographics
NPI:1124644711
Name:DINGLER, SERENA OSULLIVAN
Entity type:Individual
Prefix:
First Name:SERENA
Middle Name:OSULLIVAN
Last Name:DINGLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24411
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95154-4411
Mailing Address - Country:US
Mailing Address - Phone:650-573-2502
Mailing Address - Fax:
Practice Address - Street 1:2000 ALAMEDA DE LAS PULGAS STE 200
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1293
Practice Address - Country:US
Practice Address - Phone:650-573-2502
Practice Address - Fax:650-341-0674
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA127289106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program