Basic Information
| Provider Information | |||||||||
| NPI: | 1518024827 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORST | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | SHAWN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., LMHC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2213 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503125305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152373974 | ||||||||
| FaxNumber: | 5158832692 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 PARKHILL DR | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502111354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152409474 | ||||||||
| FaxNumber: | 5159819012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 05/23/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1518024827 | 01 | IA | MAGELLAN | OTHER | 0474593 | 05 | IA | MEDICAID | 1518024827 | 01 | IA | WELLMARK BCBS | OTHER | 1474593 | 05 | IA | MEDICAID |