MEDICARE: JERRY BORMAN LPC, M.DIV.

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	1564	NM

General Provider Information

NPI Number	:	1598886392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY BORMAN LPC, M.DIV.

Provider Business Mailing Address
First Line	:	3600 MENAUL BLVD NE STE E
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-2861
Country	:	US
Telephone Number	:	505-323-3785
Fax Number	:	505-323-3850

Provider Business Practice Location Address
First Line	:	3600 MENAUL BLVD NE STE E
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-2861
Country	:	US
Telephone Number	:	505-323-3785
Fax Number	:	505-323-3850

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

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	07/09/2007

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