Provider Demographics
NPI:1679200471
Name:BOREN, COREY (PSYD)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:BOREN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 N 19TH AVE APT 52
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93245-2573
Mailing Address - Country:US
Mailing Address - Phone:916-893-4528
Mailing Address - Fax:
Practice Address - Street 1:289 N 19TH AVE APT 52
Practice Address - Street 2:
Practice Address - City:LEMOORE
Practice Address - State:CA
Practice Address - Zip Code:93245-2573
Practice Address - Country:US
Practice Address - Phone:916-893-4528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74125103TC0700X
UT11564758-4805103TC0700X
MO4521033015103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical