Provider Demographics
NPI:1679868590
Name:BORKSTROM, TED (CASAC)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:BORKSTROM
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-5346
Mailing Address - Country:US
Mailing Address - Phone:631-413-0597
Mailing Address - Fax:
Practice Address - Street 1:44 5TH ST
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-5346
Practice Address - Country:US
Practice Address - Phone:631-413-0597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)