=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013047927
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BORRIE PSYCHOLOGICAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 LOCUST AVE
-----------------------------------------------------
City | SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11733-2253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-689-1223
-----------------------------------------------------
Fax | 631-689-1223
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 LOCUST AVE
-----------------------------------------------------
City | SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11733-2253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-689-1223
-----------------------------------------------------
Fax | 631-689-1223
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | DR. RODERICK ALLEN BORRIE
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 631-689-1223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 07931
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------