Provider Demographics
NPI:1215167770
Name:WIESENBERG, MIRIE ANNE
Entity type:Individual
Prefix:
First Name:MIRIE
Middle Name:ANNE
Last Name:WIESENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRIE
Other - Middle Name:ANNE
Other - Last Name:MAHPOUR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5851 RHODES AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-1129
Mailing Address - Country:US
Mailing Address - Phone:818-634-9195
Mailing Address - Fax:
Practice Address - Street 1:66 HURLBUT ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-4025
Practice Address - Country:US
Practice Address - Phone:626-441-4221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-19
Last Update Date:2009-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner