Provider Demographics
NPI:1790736916
Name:BORMAN, TED WILLIAM (LCSW)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:WILLIAM
Last Name:BORMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 FARRELL DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3717
Mailing Address - Country:US
Mailing Address - Phone:859-331-3292
Mailing Address - Fax:859-578-2864
Practice Address - Street 1:1201 S FORT THOMAS AVE
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-2421
Practice Address - Country:US
Practice Address - Phone:859-781-5586
Practice Address - Fax:859-781-2171
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY184607OtherMEDICARE GROUP NUMBER