Healthcare Provider Details

I. General information

NPI: 1780313478
Provider Name (Legal Business Name): SUSAN BORDEN PSYCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2303 WYCLIFF ST STE W210
SAINT PAUL MN
55114-1272
US

IV. Provider business mailing address

104 SEYMOUR AVE SE
MINNEAPOLIS MN
55414-3558
US

V. Phone/Fax

Practice location:
  • Phone: 612-424-0434
  • Fax: 877-905-7069
Mailing address:
  • Phone: 612-424-0434
  • Fax: 877-905-7069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SUSAN BORDEN
Title or Position: OWNER
Credential: PMHNP
Phone: 612-424-0434