Provider Demographics
NPI:1336162072
Name:BORTH, HARRY R (MSW, LCSW, CSAC)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:R
Last Name:BORTH
Suffix:
Gender:M
Credentials:MSW, LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 N JANACEK RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-6102
Mailing Address - Country:US
Mailing Address - Phone:262-641-9050
Mailing Address - Fax:262-641-9126
Practice Address - Street 1:3535 30TH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1632
Practice Address - Country:US
Practice Address - Phone:262-842-0500
Practice Address - Fax:262-842-0502
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1059-1231041C0700X
WI1024-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39319100Medicaid
WI39319100Medicaid