Provider Demographics
NPI:1821169962
Name:BORDWELL, MARTHA (PHD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:BORDWELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5615 BROOKLYN BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3000
Mailing Address - Country:US
Mailing Address - Phone:763-531-0566
Mailing Address - Fax:763-531-0602
Practice Address - Street 1:5615 BROOKLYN BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-3000
Practice Address - Country:US
Practice Address - Phone:763-531-0566
Practice Address - Fax:763-531-0602
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2322101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN68831BOOtherBLUECROSSBLUESHIELD
MN993552500Medicaid
MN61-20302OtherMEDICA
MN102392OtherUCARE
MNHP35967OtherHEALTHPARTNERS
MN993552500Medicaid