Healthcare Provider Details

I. General information

NPI: 1952830176
Provider Name (Legal Business Name): SUSAN GERDA BORGLUM LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 MOULTON ST E
DECATUR AL
35601-2310
US

IV. Provider business mailing address

16 MOULTON ST E
DECATUR AL
35601-2310
US

V. Phone/Fax

Practice location:
  • Phone: 256-822-2375
  • Fax:
Mailing address:
  • Phone: 256-822-2375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2820
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: