=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427302454
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HARLAND TRAVIS BOREEN PSYD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2012
-----------------------------------------------------
Last Update Date | 03/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 QUEBEC AVE MENTAL HEALTH STAFF
-----------------------------------------------------
City | CORCORAN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93212-9715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-992-7100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 9TH STREET CDCR CLIENT FINANCIAL SERVICES, ROOM 205 MAIL STOP: 2-3
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94244-2020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-992-7100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY23431
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TM1800X
-----------------------------------------------------
Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TF0200X
-----------------------------------------------------
Taxonomy Name | Forensic Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------