Healthcare Provider Details

I. General information

NPI: 1427302454
Provider Name (Legal Business Name): HARLAND TRAVIS BOREEN PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 QUEBEC AVE MENTAL HEALTH STAFF
CORCORAN CA
93212-9715
US

IV. Provider business mailing address

1600 9TH STREET CDCR CLIENT FINANCIAL SERVICES, ROOM 205 MAIL STOP: 2-3
SACRAMENTO CA
94244-2020
US

V. Phone/Fax

Practice location:
  • Phone: 559-992-7100
  • Fax:
Mailing address:
  • Phone: 559-992-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY23431
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: