Healthcare Provider Details

I. General information

NPI: 1396314449
Provider Name (Legal Business Name): BERNELL HORNSBY M.A., L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 07/05/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9466 NAVAJO TRL APT 11
MORONGO VALLEY CA
92256-9823
US

IV. Provider business mailing address

9466 NAVAJO TRL APT 11
MORONGO VALLEY CA
92256-9823
US

V. Phone/Fax

Practice location:
  • Phone: 612-227-9382
  • Fax:
Mailing address:
  • Phone: 612-227-9382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401002145
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: