Provider Demographics
NPI:1659725620
Name:BORTZ, CARSON
Entity Type:Individual
Prefix:MISS
First Name:CARSON
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 1:10011 SE DIVISION ST
Mailing Address - Street 2:SUIT 305
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-1351
Mailing Address - Country:US
Mailing Address - Phone:503-335-5975
Mailing Address - Fax:
Practice Address - Street 1:10011 SE DIVISION ST
Practice Address - Street 2:#305
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1351
Practice Address - Country:US
Practice Address - Phone:503-335-5975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor