Provider Demographics
NPI:1215664891
Name:BORTNIK, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BORTNIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12850 SW 71ST AVE
Mailing Address - Street 2:
Mailing Address - City:PINECREST
Mailing Address - State:FL
Mailing Address - Zip Code:33156-6273
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12850 SW 71ST AVE
Practice Address - Street 2:
Practice Address - City:PINECREST
Practice Address - State:FL
Practice Address - Zip Code:33156-6273
Practice Address - Country:US
Practice Address - Phone:305-484-8826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
VA2202010972235Z00000X
FLSA21701235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist