Provider Demographics
NPI:1629234273
Name:BORDEN, BROOKE ANN (MFT INTERN)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ANN
Last Name:BORDEN
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:749 DANIELLE ST
Mailing Address - Street 2:
Mailing Address - City:ESCALON
Mailing Address - State:CA
Mailing Address - Zip Code:95320-8546
Mailing Address - Country:US
Mailing Address - Phone:209-579-4845
Mailing Address - Fax:
Practice Address - Street 1:749 DANIELLE ST
Practice Address - Street 2:
Practice Address - City:ESCALON
Practice Address - State:CA
Practice Address - Zip Code:95320-8546
Practice Address - Country:US
Practice Address - Phone:209-579-4845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56998106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist