Provider Demographics
NPI:1609091719
Name:BORAS, AVERY ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:ROBERT
Last Name:BORAS
Suffix:
Gender:M
Credentials:MD
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 3850
Mailing Address - Street 2:23515 HWY 190
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-3850
Mailing Address - Country:US
Mailing Address - Phone:985-626-6300
Mailing Address - Fax:985-626-6467
Practice Address - Street 1:23515 HWY 190
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70470
Practice Address - Country:US
Practice Address - Phone:985-626-6300
Practice Address - Fax:985-626-6467
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA964103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist