Provider Demographics
NPI:1407233869
Name:BOORTZ, KASSANDRA (LMFT #105335)
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:
Last Name:BOORTZ
Suffix:
Gender:F
Credentials:LMFT #105335
Other - Prefix:
Other - First Name:KASSANDRA
Other - Middle Name:
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:I-MFT
Mailing Address - Street 1:881 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-5410
Mailing Address - Country:US
Mailing Address - Phone:805-888-1732
Mailing Address - Fax:
Practice Address - Street 1:881 PRIMROSE LN
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-5410
Practice Address - Country:US
Practice Address - Phone:805-888-1732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAI-MFT 77794106H00000X
CA105335106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist