Provider Demographics
NPI:1043353030
Name:BORAKOVE, LARRY S (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:S
Last Name:BORAKOVE
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 1:75 ZUKOR RD
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-5507
Mailing Address - Country:US
Mailing Address - Phone:914-714-5023
Mailing Address - Fax:845-634-0806
Practice Address - Street 1:55 OLD NYACK TPKE
Practice Address - Street 2:SUITE 601
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954-2461
Practice Address - Country:US
Practice Address - Phone:914-714-5023
Practice Address - Fax:845-634-0806
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011044103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02192671Medicaid
NY02192671Medicaid