Provider Demographics
NPI:1144598202
Name:BORG, LORI MARIE (MA)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:MARIE
Last Name:BORG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23405 W. LE BOST
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375
Mailing Address - Country:US
Mailing Address - Phone:313-283-3112
Mailing Address - Fax:
Practice Address - Street 1:705 S MAIN ST
Practice Address - Street 2:SUITE 280
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-2089
Practice Address - Country:US
Practice Address - Phone:734-454-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1846640103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N65400OtherHAP PIN
MI10408OtherBCBSM PIN
MI0N65400Medicare PIN