Provider Demographics
NPI:1992481535
Name:WIDA, JULIANNA AMY (BCTMB, BS,)
Entity type:Individual
Prefix:
First Name:JULIANNA
Middle Name:AMY
Last Name:WIDA
Suffix:
Gender:F
Credentials:BCTMB, BS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:734 BUSH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2903
Mailing Address - Country:US
Mailing Address - Phone:619-246-1112
Mailing Address - Fax:
Practice Address - Street 1:3505 CAMINO DEL RIO S STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4015
Practice Address - Country:US
Practice Address - Phone:619-246-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
CA613930-12225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer