Provider Demographics
NPI:1255418935
Name:BORK, MARILOU G (LCSW)
Entity type:Individual
Prefix:
First Name:MARILOU
Middle Name:G
Last Name:BORK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2334 LONDON LN
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-7409
Mailing Address - Country:US
Mailing Address - Phone:918-230-8831
Mailing Address - Fax:
Practice Address - Street 1:2334 LONDON LN
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006
Practice Address - Country:US
Practice Address - Phone:918-230-8831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13951041C0700X
KS13741041C0700X
OK381106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist