Provider Demographics
NPI:1851638159
Name:BORGSTROM, MARY KAY (RN, PMHCNS-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:BORGSTROM
Suffix:
Gender:F
Credentials:RN, PMHCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22594 N SHORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063
Mailing Address - Country:US
Mailing Address - Phone:612-419-6417
Mailing Address - Fax:
Practice Address - Street 1:905 FOREST AVE E STE 150
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1632
Practice Address - Country:US
Practice Address - Phone:320-679-6325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1108422163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult