Provider Demographics
NPI:1760200851
Name:BORNFRIEND, MIA TAYLOR (LMSW)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:TAYLOR
Last Name:BORNFRIEND
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 HAVEMEYER LN
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-2033
Mailing Address - Country:US
Mailing Address - Phone:631-538-5890
Mailing Address - Fax:
Practice Address - Street 1:1056 W JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3212
Practice Address - Country:US
Practice Address - Phone:631-656-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-28
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124706104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker