=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932348950
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARVIN MICHAEL BORNSCHLEGL LCPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2009
-----------------------------------------------------
Last Update Date | 02/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1460 RENAISSANCE DR SUITE 211
-----------------------------------------------------
City | PARK RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60068-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-391-4180
-----------------------------------------------------
Fax | 847-391-4188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1460 RENAISSANCE DR SUITE 211
-----------------------------------------------------
City | PARK RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60068-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-391-4180
-----------------------------------------------------
Fax | 847-391-4188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 180.006907
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------