Healthcare Provider Details

I. General information

NPI: 1497213789
Provider Name (Legal Business Name): ASHA BORLAND PLPC, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ASHA WALLACE

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E BROADWAY STE 304
COLUMBIA MO
65201-4469
US

IV. Provider business mailing address

601 E BROADWAY STE 304
COLUMBIA MO
65201-4469
US

V. Phone/Fax

Practice location:
  • Phone: 630-923-9516
  • Fax:
Mailing address:
  • Phone: 630-923-9516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2024039490
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: