Provider Demographics
NPI:1508473869
Name:BORAK, ALLYSSA LYNN
Entity Type:Individual
Prefix:
First Name:ALLYSSA
Middle Name:LYNN
Last Name:BORAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 HUEBNER RD
Mailing Address - Street 2:
Mailing Address - City:FT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-4030
Mailing Address - Country:US
Mailing Address - Phone:785-239-3637
Mailing Address - Fax:
Practice Address - Street 1:650 HUEBNER RD
Practice Address - Street 2:
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-4030
Practice Address - Country:US
Practice Address - Phone:785-239-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810007918103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical