Healthcare Provider Details

I. General information

NPI: 1346704152
Provider Name (Legal Business Name): MILDRED ITASKA BOROWSKI LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3790 NORTH HIGHWAY 41 SUITE A
VALDOSTA GA
31602
US

IV. Provider business mailing address

113 MAPLE ST
THOMASVILLE GA
31792-4120
US

V. Phone/Fax

Practice location:
  • Phone: 229-262-1000
  • Fax: 229-262-1085
Mailing address:
  • Phone: 229-740-2771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC007236
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: