=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982353801
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINE LYNN BORNT LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2022
-----------------------------------------------------
Last Update Date | 03/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5317 SACANDAGA RD
-----------------------------------------------------
City | GALWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12074-2423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-882-1221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 408 S WILLIAM ST
-----------------------------------------------------
City | JOHNSTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12095-2914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-706-7560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 093040
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------