Provider Demographics
NPI:1851880363
Name:BORODIN, ALEXIS
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:BORODIN
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 1:6389 GREEN NEEDLE DR
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-7119
Mailing Address - Country:US
Mailing Address - Phone:724-219-5722
Mailing Address - Fax:
Practice Address - Street 1:1405 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-3006
Practice Address - Country:US
Practice Address - Phone:815-654-4502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2024-08-27
Deactivation Date:2018-07-09
Deactivation Code:
Reactivation Date:2024-08-27
Provider Licenses
StateLicense IDTaxonomies
IL146013480235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty