Provider Demographics
NPI:1659888469
Name:BORDEWICK, MIREYA
Entity Type:Individual
Prefix:
First Name:MIREYA
Middle Name:
Last Name:BORDEWICK
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 1:1300 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ROCK FALLS
Mailing Address - State:IL
Mailing Address - Zip Code:61071-1005
Mailing Address - Country:US
Mailing Address - Phone:815-626-2230
Mailing Address - Fax:
Practice Address - Street 1:1300 W 2ND ST
Practice Address - Street 2:
Practice Address - City:ROCK FALLS
Practice Address - State:IL
Practice Address - Zip Code:61071
Practice Address - Country:US
Practice Address - Phone:815-626-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150102770101YM0800X, 104100000X
IL1490210861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker