Provider Demographics
NPI:1881961530
Name:BOREK, MARISA (NPP)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:BOREK
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:BOREK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 BREWSTER LN
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-2921
Mailing Address - Country:US
Mailing Address - Phone:631-834-7119
Mailing Address - Fax:
Practice Address - Street 1:15 BREWSTER LN
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2921
Practice Address - Country:US
Practice Address - Phone:631-834-7119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-23
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400426364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult