Provider Demographics
NPI:1285318477
Name:BORTOLOTTI, LOUISE M
Entity type:Individual
Prefix:
First Name:LOUISE
Middle Name:M
Last Name:BORTOLOTTI
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:PO BOX 4592
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95402-4592
Mailing Address - Country:US
Mailing Address - Phone:707-570-9025
Mailing Address - Fax:
Practice Address - Street 1:117 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2952
Practice Address - Country:US
Practice Address - Phone:707-570-9025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40083225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist