Provider Demographics
NPI:1063848612
Name:BORTINGER, ILANA
Entity Type:Individual
Prefix:
First Name:ILANA
Middle Name:
Last Name:BORTINGER
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 1:54 GOSS AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-4942
Mailing Address - Country:US
Mailing Address - Phone:845-729-7347
Mailing Address - Fax:
Practice Address - Street 1:54 GOSS AVE
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-4942
Practice Address - Country:US
Practice Address - Phone:845-729-7347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-15
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7704235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist