MEDICARE: GARY BORJESSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	101YM0800X	OR
2	101YP2500X	Professional Counselor	C5021	OR
3	101YM0800X	Mental Health Counselor	C5021	OR

General Provider Information

NPI Number	:	1114644531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY BORJESSON

Provider Business Mailing Address
First Line	:	184 CLEAR CREEK DR STE 1
Second Line	:
City	:	ASHLAND
State	:	OR
Zip	:	97520-1977
Country	:	US
Telephone Number	:	541-236-4437
Fax Number	:

Provider Business Practice Location Address
First Line	:	184 CLEAR CREEK DR STE 1
Second Line	:
City	:	ASHLAND
State	:	OR
Zip	:	97520-1977
Country	:	US
Telephone Number	:	541-236-4437
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2022
Last Update Date	:	10/26/2022

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Directions to “ GARY BORJESSON ” Practice Location

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