Provider Demographics
NPI:1265558316
Name:BORG, DANE M (PSYD)
Entity type:Individual
Prefix:DR
First Name:DANE
Middle Name:M
Last Name:BORG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 NE 19TH AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2686
Mailing Address - Country:US
Mailing Address - Phone:503-235-6256
Mailing Address - Fax:503-764-9646
Practice Address - Street 1:847 NE 19TH AVE STE 150
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2686
Practice Address - Country:US
Practice Address - Phone:503-235-6256
Practice Address - Fax:503-764-9646
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1578103TH0100X, 103T00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist