Healthcare Provider Details

I. General information

NPI: 1346645777
Provider Name (Legal Business Name): PATRICIA BOOTZIN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 NW CIVIC DR SUTIE 310
GRESHAM OR
97030-3770
US

IV. Provider business mailing address

440 NW ANGELINE AVE
GRESHAM OR
97030-5318
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-8832
  • Fax: 503-669-8641
Mailing address:
  • Phone: 503-806-6024
  • Fax: 503-492-6708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC3293
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: