Provider Demographics
NPI:1265994149
Name:BORTNICK, ROSALIE
Entity type:Individual
Prefix:
First Name:ROSALIE
Middle Name:
Last Name:BORTNICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 HUNGERFORD DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-1718
Mailing Address - Country:US
Mailing Address - Phone:301-840-7161
Mailing Address - Fax:
Practice Address - Street 1:18425 FLOWER HILL WAY
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-4600
Practice Address - Country:US
Practice Address - Phone:301-840-7161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06419235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD06419Medicaid