MEDICARE: KASSANDRA BOORTZ LMFT #105335

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	I-MFT 77794	CA
2	106H00000X	Marriage & Family Therapist	105335	CA

General Provider Information

NPI Number	:	1407233869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KASSANDRA BOORTZ LMFT #105335

Provider Business Mailing Address
First Line	:	881 PRIMROSE LN
Second Line	:
City	:	NIPOMO
State	:	CA
Zip	:	93444-5410
Country	:	US
Telephone Number	:	805-888-1732
Fax Number	:

Provider Business Practice Location Address
First Line	:	881 PRIMROSE LN
Second Line	:
City	:	NIPOMO
State	:	CA
Zip	:	93444-5410
Country	:	US
Telephone Number	:	805-888-1732
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2015
Last Update Date	:	02/17/2023

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