Healthcare Provider Details

I. General information

NPI: 1295932804
Provider Name (Legal Business Name): JEFFREY S BORMASTER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2193 S CALLE PALO FIERRO
PALM SPRINGS CA
92264-9079
US

IV. Provider business mailing address

2193 S CALLE PALO FIERRO
PALM SPRINGS CA
92264-9079
US

V. Phone/Fax

Practice location:
  • Phone: 760-333-9056
  • Fax:
Mailing address:
  • Phone: 760-333-9056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS15130
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: