MEDICARE: MISS EN SORM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374700000X	Technician	PT28784	CA
2	167G00000X	Licensed Psychiatric Technician	PT28784	CA

General Provider Information

NPI Number	:	1518076249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS EN SORM

Provider Business Mailing Address
First Line	:	1803 W MARCH LN STE AC&D
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-6458
Country	:	US
Telephone Number	:	209-636-5353
Fax Number	:	209-636-5356

Provider Business Practice Location Address
First Line	:	1803 W MARCH LN STE AC&D
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-6458
Country	:	US
Telephone Number	:	209-636-5353
Fax Number	:	209-636-5356

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	08/21/2023

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Directions to “ MISS EN SORM ” Practice Location

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