Basic Information
| Provider Information | |||||||||
| NPI: | 1780722009 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORLAND | ||||||||
| FirstName: | MARGO | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PMHCNS-PP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 770 SE KANE ST | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974703943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415809899 | ||||||||
| FaxNumber: | 5416732270 | ||||||||
| Practice Location | |||||||||
| Address1: | 770 SE KANE ST | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974703943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415809899 | ||||||||
| FaxNumber: | 5416732270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 08/04/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 662 | AK | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 163WP0809X | 200970008CNS-PP | OR | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 163WP0808X | 200970008CNS-PP | OR | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 500642555 | 05 | OR | MEDICAID | PENDING | 05 | AK | MEDICAID |