Provider Demographics
NPI:1235163957
Name:DORNBUSH, BECKY S (MA LMFT)
Entity Type:Individual
Prefix:MS
First Name:BECKY
Middle Name:S
Last Name:DORNBUSH
Suffix:
Gender:F
Credentials:MA LMFT
Other - Prefix:MS
Other - First Name:BECKY
Other - Middle Name:S
Other - Last Name:LOOMIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 33RD AVE N STE 103
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1929
Mailing Address - Country:US
Mailing Address - Phone:320-253-3715
Mailing Address - Fax:320-252-2567
Practice Address - Street 1:325 33RD AVE N STE 103
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1929
Practice Address - Country:US
Practice Address - Phone:320-253-3715
Practice Address - Fax:320-252-2567
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1423106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist