MEDICARE: INGRID MARIE BORNIA LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904007772	VA

General Provider Information

NPI Number	:	1427328384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	INGRID MARIE BORNIA LCSW

Provider Business Mailing Address
First Line	:	110 COLISEUM CROSSING
Second Line	:	#138
City	:	HAMPTON
State	:	VA
Zip	:	23666-5962
Country	:	US
Telephone Number	:	757-893-0321
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 COLISEUM CROSSING
Second Line	:	# 138
City	:	HAMPTON
State	:	VA
Zip	:	23666-5971
Country	:	US
Telephone Number	:	757-893-0321
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2012
Last Update Date	:	04/16/2019

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