Provider Demographics
NPI:1659413680
Name:NYBORG, KATHLEEN F (PHD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:F
Last Name:NYBORG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:F
Other - Last Name:NYBORG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 151
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:ME
Mailing Address - Zip Code:04664
Mailing Address - Country:US
Mailing Address - Phone:207-667-3795
Mailing Address - Fax:
Practice Address - Street 1:210 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605
Practice Address - Country:US
Practice Address - Phone:207-667-3795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS585103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME223660000Medicaid
MEX0298OtherANTHEM BC BS
MEMM3065Medicare ID - Type Unspecified