Provider Demographics
NPI:1962682054
Name:BORNT, ROBERT K (MFT)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:K
Last Name:BORNT
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37028
Mailing Address - Street 2:
Mailing Address - City:TOKSOOK BAY
Mailing Address - State:AK
Mailing Address - Zip Code:99637-0028
Mailing Address - Country:US
Mailing Address - Phone:907-843-2661
Mailing Address - Fax:
Practice Address - Street 1:700 CHIEF EDDIE HOFFMAN HWY
Practice Address - Street 2:150
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-843-2661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC43663101YM0800X
AK261106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH0150Medicaid