Provider Demographics
NPI:1811211808
Name:BORN, KATHLNE MAY (LISAC)
Entity Type:Individual
Prefix:MRS
First Name:KATHLNE
Middle Name:MAY
Last Name:BORN
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 N CENTRAL AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1315
Mailing Address - Country:US
Mailing Address - Phone:480-507-8619
Mailing Address - Fax:480-507-8618
Practice Address - Street 1:943 S GILBERT RD STE 204
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-4441
Practice Address - Country:US
Practice Address - Phone:480-507-8619
Practice Address - Fax:480-507-8618
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10955101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ#101YM0800XMedicaid