Provider Demographics
NPI:1356178255
Name:DORR, CLARISSA (PPS CREDENTIAL)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
Last Name:DORR
Suffix:
Gender:F
Credentials:PPS CREDENTIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 W D ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-3026
Mailing Address - Country:US
Mailing Address - Phone:909-624-0029
Mailing Address - Fax:
Practice Address - Street 1:4724 SAN JOSE ST.
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763
Practice Address - Country:US
Practice Address - Phone:909-624-0029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240161424101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool