Provider Demographics
NPI:1992292361
Name:BORDEN, STACEY K (MED, LADC-1)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:K
Last Name:BORDEN
Suffix:
Gender:F
Credentials:MED, LADC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 DRYDOCK AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02210-2386
Mailing Address - Country:US
Mailing Address - Phone:857-237-2780
Mailing Address - Fax:616-507-6176
Practice Address - Street 1:22 DRYDOCK AVE FL 3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02210-2386
Practice Address - Country:US
Practice Address - Phone:857-237-2780
Practice Address - Fax:617-507-6176
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA14960101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA81-1525549OtherMASSACHUSETTS INSURERS