Healthcare Provider Details

I. General information

NPI: 1386766095
Provider Name (Legal Business Name): MARC BORKHEIM PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

864 S ROBERTSON BLVD STE 104
LOS ANGELES CA
90035-1622
US

IV. Provider business mailing address

10990 ROCHESTER AVE 312
LOS ANGELES CA
90024-6274
US

V. Phone/Fax

Practice location:
  • Phone: 617-304-5256
  • Fax:
Mailing address:
  • Phone: 617-304-5256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number22988
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number22988
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: