Healthcare Provider Details

I. General information

NPI: 1265558316
Provider Name (Legal Business Name): DANE M BORG PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

847 NE 19TH AVE STE 150
PORTLAND OR
97232-2686
US

IV. Provider business mailing address

847 NE 19TH AVE STE 150
PORTLAND OR
97232-2686
US

V. Phone/Fax

Practice location:
  • Phone: 503-235-6256
  • Fax: 503-764-9646
Mailing address:
  • Phone: 503-235-6256
  • Fax: 503-764-9646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number1578
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1578
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: