Healthcare Provider Details

I. General information

NPI: 1356178255
Provider Name (Legal Business Name): CLARISSA DORR PPS CREDENTIAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4724 SAN JOSE ST.
MONTCLAIR CA
91763
US

IV. Provider business mailing address

950 W D ST
ONTARIO CA
91762-3026
US

V. Phone/Fax

Practice location:
  • Phone: 909-624-0029
  • Fax:
Mailing address:
  • Phone: 909-624-0029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number240161424
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: