Provider Demographics
NPI:1710082631
Name:IMBORNONI, STEPHEN (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:IMBORNONI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23300 CHAGRIN BLVD
Mailing Address - Street 2:#202
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5557
Mailing Address - Country:US
Mailing Address - Phone:216-973-0565
Mailing Address - Fax:
Practice Address - Street 1:23300 CHAGRIN BLVD
Practice Address - Street 2:#202
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5557
Practice Address - Country:US
Practice Address - Phone:216-973-0565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5196103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist