Healthcare Provider Details

I. General information

NPI: 1225560949
Provider Name (Legal Business Name): DAVID M BORTNICK PHD PSY D PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 TREE BLVD STE 5
ST AUGUSTINE FL
32084-5719
US

IV. Provider business mailing address

PO BOX 3123
ST AUGUSTINE FL
32085-3123
US

V. Phone/Fax

Practice location:
  • Phone: 904-342-0672
  • Fax: 904-342-0673
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY2065
License Number StateFL

VIII. Authorized Official

Name: DR. DAVID M BORTNICK
Title or Position: OWNER PRESIDENT
Credential: PHD PSYD ABN
Phone: 904-392-1687