Provider Demographics
NPI:1679794382
Name:BORMAN-BURMAN, WENDY COLEEN (LSW)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:COLEEN
Last Name:BORMAN-BURMAN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:COLEEN
Other - Last Name:LAMONTAGNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:PO BOX 1995
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-1995
Mailing Address - Country:US
Mailing Address - Phone:701-255-2773
Mailing Address - Fax:701-255-6261
Practice Address - Street 1:513 E BISMARCK EXPY
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-6577
Practice Address - Country:US
Practice Address - Phone:701-255-2773
Practice Address - Fax:701-255-6261
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3005171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND74047Medicaid