Provider Demographics
NPI:1548712011
Name:DIMENGO, JEFF (OTR/L)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:DIMENGO
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 GARDENSIDE DR
Mailing Address - Street 2:APT 303
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94131-1325
Mailing Address - Country:US
Mailing Address - Phone:330-990-2030
Mailing Address - Fax:
Practice Address - Street 1:2425 GEARY BLVD
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3358
Practice Address - Country:US
Practice Address - Phone:415-833-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-31
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12507225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12507OtherBOARD OF OCCUPATIONAL THERAPY