Provider Demographics
NPI:1194494732
Name:BORTNICK, KEVIN (OTD, OT/L)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BORTNICK
Suffix:
Gender:M
Credentials:OTD, OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1098 PERSIAN LN
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-5456
Mailing Address - Country:US
Mailing Address - Phone:248-242-1332
Mailing Address - Fax:
Practice Address - Street 1:221 W HALLANDALE BEACH BLVD STE 112
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-5441
Practice Address - Country:US
Practice Address - Phone:786-770-9480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15422225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist