Provider Demographics
NPI:1982648887
Name:BORDEWICK, MARK C (PHD LP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:C
Last Name:BORDEWICK
Suffix:
Gender:M
Credentials:PHD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 13TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2614
Mailing Address - Country:US
Mailing Address - Phone:320-252-5010
Mailing Address - Fax:320-203-1855
Practice Address - Street 1:1321 13TH ST N
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2614
Practice Address - Country:US
Practice Address - Phone:320-252-5010
Practice Address - Fax:320-203-1855
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0984103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
6100032OtherMEDICA
MN095248600Medicaid
117014C851OtherUCARE
922241012150OtherPREFERRED ONE
44544OtherOPTUM
HP25562OtherHEALTH PARTNERS
03Q37B0OtherBCBS
MN095248600Medicaid