Provider Demographics
NPI:1790499184
Name:BORDENKIRCHER, MELISSA (LAC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BORDENKIRCHER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7982 W MARTHA WAY
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4350
Mailing Address - Country:US
Mailing Address - Phone:623-244-0834
Mailing Address - Fax:
Practice Address - Street 1:4425 W OLIVE AVE STE 301
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-3851
Practice Address - Country:US
Practice Address - Phone:623-755-9690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC21648101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional