Provider Demographics
NPI:1225357767
Name:BORTNYIK, REBECCA A (LMHC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:BORTNYIK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 E OAKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-3547
Mailing Address - Country:US
Mailing Address - Phone:850-682-1234
Mailing Address - Fax:
Practice Address - Street 1:7 VINE AVE NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5070
Practice Address - Country:US
Practice Address - Phone:850-833-7400
Practice Address - Fax:850-833-7528
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2014-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 10296101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002123500Medicaid