Provider Demographics
NPI:1194033563
Name:SORNBORGER, JO (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JO
Middle Name:
Last Name:SORNBORGER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1554 S SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3377
Mailing Address - Country:US
Mailing Address - Phone:310-949-9242
Mailing Address - Fax:
Practice Address - Street 1:1554 S SEPULVEDA BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3377
Practice Address - Country:US
Practice Address - Phone:310-949-9242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23276103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFX619ZMedicare PIN