Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | PY9600 | FL |
Y | 103TC0700X | Clinical Psychologist | PY9600 | FL |
NPI | 1003362740 |
---|---|
Provider Name | Cara Bortz |
First Address | Melbourne, FL 32902-1137 |
Second Address | Titusville, FL 32796-2759 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/09/2016 |
Last Update Date | 16/11/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
018686200 | (05) | FL |