Healthcare Provider Details

I. General information

NPI: 1982648887
Provider Name (Legal Business Name): MARK C BORDEWICK PHD LP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 13TH ST N
ST CLOUD MN
56303-2614
US

IV. Provider business mailing address

1321 13TH ST N
ST CLOUD MN
56303-2614
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-5010
  • Fax: 320-203-1855
Mailing address:
  • Phone: 320-252-5010
  • Fax: 320-203-1855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP0984
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: