Provider Demographics
NPI:1962819540
Name:BORCHARDT, SUSAN MARIE
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:BORCHARDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 INDIAN CIR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-6214
Mailing Address - Country:US
Mailing Address - Phone:804-490-1639
Mailing Address - Fax:
Practice Address - Street 1:4430 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-9098
Practice Address - Country:US
Practice Address - Phone:573-596-0522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
NCC0102271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical