Healthcare Provider Details

I. General information

NPI: 1689596868
Provider Name (Legal Business Name): ANDREA PSALM BORDEN IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GRAMERCY PARK DR APT 414
BRYAN TX
77802-4542
US

IV. Provider business mailing address

21 GRAMERCY PARK DR APT 414
BRYAN TX
77802-4542
US

V. Phone/Fax

Practice location:
  • Phone: 254-723-5175
  • Fax:
Mailing address:
  • Phone: 254-723-5175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-322378
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: