Provider Demographics
NPI:1962012278
Name:DORNBERGER, DORIS ANN
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:ANN
Last Name:DORNBERGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DORIS
Other - Middle Name:ANN
Other - Last Name:TANKERSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19W020 13TH ST
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4739
Mailing Address - Country:US
Mailing Address - Phone:630-222-1966
Mailing Address - Fax:
Practice Address - Street 1:19W020 13TH ST
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4739
Practice Address - Country:US
Practice Address - Phone:630-222-1966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0048811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical