Provider Demographics
NPI:1598807992
Name:BORG, MARK B JR (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:B
Last Name:BORG
Suffix:JR
Gender:M
Credentials:PHD
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Mailing Address - Street 1:1133 BROADWAY
Mailing Address - Street 2:SUITE 920
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-8218
Mailing Address - Country:US
Mailing Address - Phone:212-978-0266
Mailing Address - Fax:212-741-1697
Practice Address - Street 1:1133 BROADWAY
Practice Address - Street 2:SUITE 920
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-8218
Practice Address - Country:US
Practice Address - Phone:212-978-0266
Practice Address - Fax:212-741-1697
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2012-08-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY013891103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01943402Medicaid
NY01943402Medicaid