Provider Demographics
NPI:1063166536
Name:BOREN, ALIDA MARIE
Entity type:Individual
Prefix:
First Name:ALIDA
Middle Name:MARIE
Last Name:BOREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8556
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59904-1556
Mailing Address - Country:US
Mailing Address - Phone:406-366-6109
Mailing Address - Fax:
Practice Address - Street 1:108 W RESERVE DR
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-2118
Practice Address - Country:US
Practice Address - Phone:406-366-6109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBHH-LCPC-LIC63965101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health