Provider Demographics
NPI:1164620969
Name:BORKOSKY, BRUCE GLENN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:GLENN
Last Name:BORKOSKY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-7928
Mailing Address - Country:US
Mailing Address - Phone:304-837-2782
Mailing Address - Fax:813-200-8450
Practice Address - Street 1:1800 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-7928
Practice Address - Country:US
Practice Address - Phone:304-837-2782
Practice Address - Fax:813-200-8450
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5159103T00000X, 103TF0200X, 171M00000X
103G00000X, 103TA0700X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59655Medicare UPIN