MEDICARE: MILDRED ITASKA BOROWSKI LPC

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	101YM0800X	Mental Health Counselor	LPC007236	GA

General Provider Information

NPI Number	:	1346704152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MILDRED ITASKA BOROWSKI LPC

Provider Business Mailing Address
First Line	:	113 MAPLE ST
Second Line	:
City	:	THOMASVILLE
State	:	GA
Zip	:	31792-4120
Country	:	US
Telephone Number	:	229-740-2771
Fax Number	:

Provider Business Practice Location Address
First Line	:	3790 NORTH HIGHWAY 41
Second Line	:	SUITE A
City	:	VALDOSTA
State	:	GA
Zip	:	31602
Country	:	US
Telephone Number	:	229-262-1000
Fax Number	:	229-262-1085

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

Provider Enumeration Date	:	01/25/2019
Last Update Date	:	01/25/2019

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