Healthcare Provider Details

I. General information

NPI: 1114669603
Provider Name (Legal Business Name): NICOLE MARGIT BORBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE DUTRA MSW, ASW

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1742 OREGON ST
REDDING CA
96001-1717
US

IV. Provider business mailing address

1742 OREGON ST
REDDING CA
96001-1717
US

V. Phone/Fax

Practice location:
  • Phone: 530-646-7269
  • Fax: 530-275-2201
Mailing address:
  • Phone: 530-646-7269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: