Basic Information
| Provider Information | |||||||||
| NPI: | 1346645777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOOTZIN | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 NW ANGELINE AVE | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970305318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038066024 | ||||||||
| FaxNumber: | 5034926708 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 NW CIVIC DR | ||||||||
| Address2: | SUTIE 310 | ||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970303770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036668832 | ||||||||
| FaxNumber: | 5036698641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2014 | ||||||||
| LastUpdateDate: | 10/28/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C3293 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.