Provider Demographics
NPI:1225649684
Name:BORUM, KHALIO (MS, LPC-IT)
Entity Type:Individual
Prefix:
First Name:KHALIO
Middle Name:
Last Name:BORUM
Suffix:
Gender:M
Credentials:MS, LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1115
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53052-1115
Mailing Address - Country:US
Mailing Address - Phone:414-435-0333
Mailing Address - Fax:
Practice Address - Street 1:4025 N 92ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1613
Practice Address - Country:US
Practice Address - Phone:414-435-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4681-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health