Provider Demographics
NPI:1093827180
Name:BORGERT, MARY LOU (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LOU
Last Name:BORGERT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-1532
Mailing Address - Country:US
Mailing Address - Phone:269-278-2003
Mailing Address - Fax:269-278-1507
Practice Address - Street 1:30 N MAIN ST
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-1532
Practice Address - Country:US
Practice Address - Phone:269-278-2003
Practice Address - Fax:269-278-1507
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008346103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI304168OtherMHN NORTH
MI0N75810Medicare PIN