Healthcare Provider Details

I. General information

NPI: 1215202783
Provider Name (Legal Business Name): CORNELIA GRACE BJORGE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2012
Last Update Date: 03/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41765 12TH ST W STE D
PALMDALE CA
93551-1422
US

IV. Provider business mailing address

41765 12TH ST W STE D
PALMDALE CA
93551-1422
US

V. Phone/Fax

Practice location:
  • Phone: 661-940-4861
  • Fax: 661-942-4511
Mailing address:
  • Phone: 661-940-4861
  • Fax: 661-942-4511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC35634
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: