Healthcare Provider Details

I. General information

NPI: 1962971242
Provider Name (Legal Business Name): STEPHANIE ANNE BORN PSYD, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2018
Last Update Date: 11/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 6TH AVE N
SAINT CLOUD MN
56303-1900
US

IV. Provider business mailing address

2205 MEADOW OAK AVE APT 234
MONTICELLO MN
55362-2611
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-7891
  • Fax:
Mailing address:
  • Phone: 612-382-4275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6319
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: