Provider Demographics
NPI:1376748780
Name:BORTNIK, KIRSTY E (PHD)
Entity Type:Individual
Prefix:
First Name:KIRSTY
Middle Name:E
Last Name:BORTNIK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1493
Mailing Address - Street 2:
Mailing Address - City:SIERRA MADRE
Mailing Address - State:CA
Mailing Address - Zip Code:91025-4493
Mailing Address - Country:US
Mailing Address - Phone:212-305-3247
Mailing Address - Fax:
Practice Address - Street 1:1301 20TH ST STE 150
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2050
Practice Address - Country:US
Practice Address - Phone:310-458-2764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32126103TC0700X, 103G00000X
NY019916103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical