Provider Demographics
NPI:1871647941
Name:DESCHAMBAULT-BORSA, TINA MARIE (MA)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:MARIE
Last Name:DESCHAMBAULT-BORSA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 MAIN ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-3701
Mailing Address - Country:US
Mailing Address - Phone:603-283-1534
Mailing Address - Fax:603-357-6859
Practice Address - Street 1:64 MAIN ST
Practice Address - Street 2:SUITE 301
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-3701
Practice Address - Country:US
Practice Address - Phone:603-283-1534
Practice Address - Fax:603-357-6859
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC3711101YM0800X
MA6909101YM0800X
NH898101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health