Provider Demographics
NPI:1942759782
Name:KORNBACHER, SUSAN MARGARET
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARGARET
Last Name:KORNBACHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 BOYS REPUBLIC DR
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-5447
Mailing Address - Country:US
Mailing Address - Phone:909-628-1217
Mailing Address - Fax:909-627-9222
Practice Address - Street 1:1907 BOYS REPUBLIC DR
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-5447
Practice Address - Country:US
Practice Address - Phone:909-628-1217
Practice Address - Fax:909-627-9222
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT18969106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist