Provider Demographics
NPI:1427715523
Name:BORGSTROM, SANDRA MARIE
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:MARIE
Last Name:BORGSTROM
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 1:2430 FAIRCHILD LN
Mailing Address - Street 2:
Mailing Address - City:WEST CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60185-6165
Mailing Address - Country:US
Mailing Address - Phone:630-639-3470
Mailing Address - Fax:
Practice Address - Street 1:240 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2905
Practice Address - Country:US
Practice Address - Phone:630-377-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0077981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical