Healthcare Provider Details

I. General information

NPI: 1154427631
Provider Name (Legal Business Name): VON F. BORG LPCC, LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

YOKOTA AIR BASE UNIT 5071
APO AP
96328
US

IV. Provider business mailing address

PO BOX 302
BEAVER BAY MN
55601-0302
US

V. Phone/Fax

Practice location:
  • Phone: 315-225-8391
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number257
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number304451
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1446
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC00184
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: