Provider Demographics
NPI:1053010710
Name:BORLAND, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BORLAND
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 1:10204 VIRTUOSO
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-0370
Mailing Address - Country:US
Mailing Address - Phone:949-307-4550
Mailing Address - Fax:
Practice Address - Street 1:2900 BRISTOL ST STE J204
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-7920
Practice Address - Country:US
Practice Address - Phone:949-441-2290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-01
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT134984106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist