Provider Demographics
NPI:1134781313
Name:DORN, RANDE
Entity type:Individual
Prefix:
First Name:RANDE
Middle Name:
Last Name:DORN
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 1:15911 KITTRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-5953
Mailing Address - Country:US
Mailing Address - Phone:818-599-2522
Mailing Address - Fax:
Practice Address - Street 1:12722 RIVERSIDE DR STE 104
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-3369
Practice Address - Country:US
Practice Address - Phone:818-599-2522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111746103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical