Provider Demographics
NPI:1295932804
Name:BORMASTER, JEFFREY S (LCSW)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:S
Last Name:BORMASTER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2193 S CALLE PALO FIERRO
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-9079
Mailing Address - Country:US
Mailing Address - Phone:760-333-9056
Mailing Address - Fax:
Practice Address - Street 1:2193 S CALLE PALO FIERRO
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-9079
Practice Address - Country:US
Practice Address - Phone:760-333-9056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS151301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS15130OtherLCSW LICENSE NO