=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699712588
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNSELING AND PSYCHOLOGICAL SERVICES OF THREE RIVERS P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 N MAIN ST
-----------------------------------------------------
City | THREE RIVERS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49093-1532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-278-2003
-----------------------------------------------------
Fax | 269-278-1507
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 N MAIN ST
-----------------------------------------------------
City | THREE RIVERS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49093-1532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-278-2003
-----------------------------------------------------
Fax | 269-278-1507
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT /SECRETARY
-----------------------------------------------------
Name | DR. MARY LOU BORGERT
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 269-278-2003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6301008346
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801065751
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------