Basic Information
| Provider Information | |||||||||
| NPI: | 1093952400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORTEL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BORTEL | ||||||||
| OtherFirstName: | MICHAEL | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | LICENSED PSYCHOLOGIS | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3450 OLEARY LN | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551232340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514540114 | ||||||||
| FaxNumber: | 6514543492 | ||||||||
| Practice Location | |||||||||
| Address1: | 3450 OLEARY LN | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551232340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514540114 | ||||||||
| FaxNumber: | 6514543492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2009 | ||||||||
| LastUpdateDate: | 01/07/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP4991 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.