Provider Demographics
NPI:1043642093
Name:BORTH, DANIEL RICHARD
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:RICHARD
Last Name:BORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N10727 OLSON ROAD
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938
Mailing Address - Country:US
Mailing Address - Phone:906-932-4273
Mailing Address - Fax:
Practice Address - Street 1:N10727 OLSON RD
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-9218
Practice Address - Country:US
Practice Address - Phone:906-932-4273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010955641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical