Provider Demographics
NPI:1508121096
Name:BOREALIS BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:BOREALIS BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:TERESE
Authorized Official - Last Name:MINER-COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:907-745-7080
Mailing Address - Street 1:634 S BAILEY ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6330
Mailing Address - Country:US
Mailing Address - Phone:907-745-7080
Mailing Address - Fax:907-745-6263
Practice Address - Street 1:634 S BAILEY ST
Practice Address - Street 2:SUITE 207
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6330
Practice Address - Country:US
Practice Address - Phone:907-745-7080
Practice Address - Fax:907-745-6263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK77106H00000X
AK86106H00000X
AK241363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty