Provider Demographics
NPI:1467222307
Name:BORTZ, ADELINE
Entity Type:Individual
Prefix:
First Name:ADELINE
Middle Name:
Last Name:BORTZ
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 1:1405 EL CAMINO REAL APT 314
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-2644
Mailing Address - Country:US
Mailing Address - Phone:970-531-4991
Mailing Address - Fax:
Practice Address - Street 1:845 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4807
Practice Address - Country:US
Practice Address - Phone:650-762-8352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34667103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent