Provider Demographics
NPI:1164804688
Name:BORTNER, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BORTNER
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 1:195 RECORDS DR
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:DE
Mailing Address - Zip Code:19962-4608
Mailing Address - Country:US
Mailing Address - Phone:610-858-4113
Mailing Address - Fax:
Practice Address - Street 1:100 DELAWARE VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-5395
Practice Address - Country:US
Practice Address - Phone:302-424-6025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-20
Last Update Date:2015-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0000844225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant