Provider Demographics
NPI:1316638117
Name:BORAGE WELLNESS CENTER
Entity type:Organization
Organization Name:BORAGE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ABREE
Authorized Official - Middle Name:SEPULVEDA
Authorized Official - Last Name:MIZE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-719-9410
Mailing Address - Street 1:4646 S 3500 W STE 2
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-9405
Mailing Address - Country:US
Mailing Address - Phone:801-719-9410
Mailing Address - Fax:
Practice Address - Street 1:4646 S 3500 W STE 2
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:UT
Practice Address - Zip Code:84401-9405
Practice Address - Country:US
Practice Address - Phone:801-719-9410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-15
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty