Basic Information
| Provider Information | |||||||||
| NPI: | 1841672821 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOROSKI | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LMFT,LADC, MA,BS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7720 | ||||||||
| Address2: | CREDENTIALING SPECIALIST | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065190720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033174 | ||||||||
| FaxNumber: | 2035033183 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 COLUMBUS AVENUE | ||||||||
| Address2: | ADULT PSYCHIATRIC CLINIC | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033075 | ||||||||
| FaxNumber: | 2035033296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2015 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1194 | CT | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 106H00000X | 1951 | CT | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 008065074 | 05 | CT | MEDICAID | 060669107 | 01 | CT | HEALTHYCT WELLMORE GRP/FACILITY | OTHER | NOT ELIGIBLE | 01 | CT | CIGNA BEHAVIORAL HEALTH | OTHER | NOT ELIGIBLE | 01 | CT | MHN TRICARENORTH | OTHER | 060669107 | 01 | CT | OPTUM BEHAVIORAL HEALTH-UBH WELLMORE FACILITY/GRP | OTHER | 060669107 | 01 | CT | UBH-OXFORD FREEDOM/LIBERTY WELLMORE GRP/FACILITY | OTHER | CAC-6129 | 01 | CT | CCB-CERTIFIED ADDICTION COUNSELOR | OTHER | 060669107 | 01 | CT | UBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY | OTHER | 10450310 402 E MAIN | 01 | CT | BEACON HEALTH STRATEGIES | OTHER | 060669107 | 01 | CT | ANTHEM BCBS OF CT WELLMORE GRP/FACILITY | OTHER | NOT ELIGIBLE | 01 | CT | MHN MANAGED HEALTH NETWORK | OTHER | ICADC-6129 | 01 | CT | CCB- INTERNATIONALLY CERTIFIED ADDICTION COUNSELOR | OTHER | 060669107 | 01 | CT | UBH-CONNECTICARE WELLMORE GRP/FACILITY | OTHER | 13823195 | 01 | CT | CAQH | OTHER | PENDING | 01 | CT | AETNA BEHAVIORAL HEALTH | OTHER |