Provider Demographics
NPI:1003824541
Name:BORER, GARY S (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
Last Name:BORER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:0-28 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3748
Mailing Address - Country:US
Mailing Address - Phone:201-791-4116
Mailing Address - Fax:
Practice Address - Street 1:0-28 PINE AVE
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3748
Practice Address - Country:US
Practice Address - Phone:201-791-4116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100170000103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0598305Medicaid
NJ0598305Medicaid