Provider Demographics
NPI:1093952400
Name:BORTEL, MICHAEL LEE (MA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:BORTEL
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:LEE
Other - Last Name:BORTEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICENSED PSYCHOLOGIS
Mailing Address - Street 1:3450 OLEARY LN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2340
Mailing Address - Country:US
Mailing Address - Phone:651-454-0114
Mailing Address - Fax:651-454-3492
Practice Address - Street 1:3450 OLEARY LN
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-2340
Practice Address - Country:US
Practice Address - Phone:651-454-0114
Practice Address - Fax:651-454-3492
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4991103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist