Healthcare Provider Details

I. General information

NPI: 1356308530
Provider Name (Legal Business Name): DAVID M BORTNICK PHD PSYD ABN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2006
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:
Title or Position:
Credential:
Phone: