Provider Demographics
NPI:1316339849
Name:BORTZNER, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:BORTZNER
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 1:2543 EMPIRE AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7577
Mailing Address - Country:US
Mailing Address - Phone:321-323-4123
Mailing Address - Fax:
Practice Address - Street 1:2543 EMPIRE AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7577
Practice Address - Country:US
Practice Address - Phone:321-323-4123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-20
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-55820103K00000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other