Provider Demographics
NPI:1184297020
Name:BORDEGARAY, SIMONE AVA I
Entity type:Individual
Prefix:MS
First Name:SIMONE
Middle Name:AVA
Last Name:BORDEGARAY
Suffix:I
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 1:448 LAUREL ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-1920
Mailing Address - Country:US
Mailing Address - Phone:650-245-1913
Mailing Address - Fax:
Practice Address - Street 1:1350 OLD BAYSHORE HWY STE 45
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-1824
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician