Basic Information
| Provider Information | |||||||||
| NPI: | 1649804998 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BORTOLUSSI | ||||||||
| FirstName: | ALEXANDRA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 E COLORADO BLVD STE 560 | ||||||||
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| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911062380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182416780 | ||||||||
| FaxNumber: | 8182416853 | ||||||||
| Practice Location | |||||||||
| Address1: | 262 WESTFIELD RD | ||||||||
| Address2: | |||||||||
| City: | HOLYOKE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010401662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182416780 | ||||||||
| FaxNumber: | 8182416853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2020 | ||||||||
| LastUpdateDate: | 06/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | 106S00000X | Y |
No ID Information.