Provider Demographics
NPI:1902286123
Name:BORNHORST, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:BORNHORST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:BORCHERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:750 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-9029
Mailing Address - Country:US
Mailing Address - Phone:937-497-2210
Mailing Address - Fax:
Practice Address - Street 1:750 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-9029
Practice Address - Country:US
Practice Address - Phone:937-497-2210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3058662103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool