Provider Demographics
NPI:1801003777
Name:BORTLE, SCOTT THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:THOMAS
Last Name:BORTLE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 MASSACHUSETTS AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-3835
Mailing Address - Country:US
Mailing Address - Phone:617-935-3384
Mailing Address - Fax:
Practice Address - Street 1:1218 MASSACHUSETTS AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-3835
Practice Address - Country:US
Practice Address - Phone:617-935-3384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9020103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical