Provider Demographics
NPI:1215245766
Name:BORGWARDT, LANI SUSAN
Entity type:Individual
Prefix:MS
First Name:LANI
Middle Name:SUSAN
Last Name:BORGWARDT
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 1:801 STANNAGE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1644
Mailing Address - Country:US
Mailing Address - Phone:510-227-0640
Mailing Address - Fax:
Practice Address - Street 1:830 B ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3003
Practice Address - Country:US
Practice Address - Phone:415-459-5843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680011405OtherMENTAL HEALTH HOUSING