Provider Demographics
NPI:1598133530
Name:BOREALI, FRED (LCSW)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:
Last Name:BOREALI
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-1729
Mailing Address - Country:US
Mailing Address - Phone:518-393-3712
Mailing Address - Fax:
Practice Address - Street 1:110 WOLF RD
Practice Address - Street 2:
Practice Address - City:COLONIE
Practice Address - State:NY
Practice Address - Zip Code:12205-1244
Practice Address - Country:US
Practice Address - Phone:518-393-3712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-08
Last Update Date:2015-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO443811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ300251108Medicare PIN