Provider Demographics
NPI:1326554858
Name:BORUCKI, JOHN ROBERT
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:BORUCKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11052 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:GARRETTSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44231-9738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 E MARKET ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44305-2421
Practice Address - Country:US
Practice Address - Phone:330-315-2654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.050244101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)