Provider Demographics
NPI:1053520924
Name:DORNBERG, SUSANA MORELL (OTR/L)
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:MORELL
Last Name:DORNBERG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 VIA LA SOLEDAD
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-6626
Mailing Address - Country:US
Mailing Address - Phone:310-920-2302
Mailing Address - Fax:
Practice Address - Street 1:2040 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-2660
Practice Address - Country:US
Practice Address - Phone:310-920-2302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 4667225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist