Provider Demographics
NPI:1720614548
Name:BORKENHAGEN, ALYCE RILEY
Entity Type:Individual
Prefix:
First Name:ALYCE
Middle Name:RILEY
Last Name:BORKENHAGEN
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 1:609 GLACIER TRL
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-1034
Mailing Address - Country:US
Mailing Address - Phone:630-373-5820
Mailing Address - Fax:
Practice Address - Street 1:609 GLACIER TRL
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172-1034
Practice Address - Country:US
Practice Address - Phone:630-373-5820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-13
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL0960056772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0926Medicaid