Healthcare Provider Details

I. General information

NPI: 1174770721
Provider Name (Legal Business Name): KATHLEEN MARY BORNARTH LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS KATHLEEN MARY BISHOP

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 E OCEAN HWY
HOLLY RIDGE NC
28445-8719
US

IV. Provider business mailing address

814 E OCEAN HWY
HOLLY RIDGE NC
28445-8714
US

V. Phone/Fax

Practice location:
  • Phone: 910-803-0981
  • Fax: 910-803-0981
Mailing address:
  • Phone: 910-803-0981
  • Fax: 910-803-0981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701004021
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2488
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: