Provider Demographics
NPI:1063673226
Name:BORNHOLDT, SHAUNE KELLY (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHAUNE
Middle Name:KELLY
Last Name:BORNHOLDT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:S
Other - Last Name:BORNHOLDT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:501 W 121ST ST
Mailing Address - Street 2:APT 52
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-5903
Mailing Address - Country:US
Mailing Address - Phone:212-662-0137
Mailing Address - Fax:
Practice Address - Street 1:1165 MORRIS PARK AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1915
Practice Address - Country:US
Practice Address - Phone:718-430-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014867103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist