MEDICARE: MARILOU G. BORK LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1395	OK

General Provider Information

NPI Number	:	1255418935
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILOU G. BORK LCSW

Provider Business Mailing Address
First Line	:	2334 LONDON LN
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006-7409
Country	:	US
Telephone Number	:	918-230-8831
Fax Number	:

Provider Business Practice Location Address
First Line	:	2334 LONDON LN
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006
Country	:	US
Telephone Number	:	918-230-8831
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	06/06/2018

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