Basic Information
| Provider Information | |||||||||
| NPI: | 1144598202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORG | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23405 W. LE BOST | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132833112 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 705 S MAIN ST | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481702089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344543560 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2011 | ||||||||
| LastUpdateDate: | 12/05/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | L1846640 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 0N65400 | 01 | MI | HAP PIN | OTHER | 10408 | 01 | MI | BCBSM PIN | OTHER |