MEDICARE: HALEY BORTNEM

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	106S00000X	Behavior Technician
2	103K00000X	Behavior Analyst	1-21-53236	TX

General Provider Information

NPI Number	:	1518592260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HALEY BORTNEM

Provider Business Mailing Address
First Line	:	4235 CEDAR SPRINGS RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-2691
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4235 CEDAR SPRINGS RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-2691
Country	:	US
Telephone Number	:	469-906-6372
Fax Number	:

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

Provider Enumeration Date	:	03/03/2020
Last Update Date	:	09/21/2021

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