Basic Information
| Provider Information | |||||||||
| NPI: | 1659917532 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORTNER | ||||||||
| FirstName: | EMILY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5639 AMAYA DR APT 293 | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5157837638 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9245 ACTIVITY RD STE 106 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921264442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584280222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2019 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | CA | N | Other Service Providers | Case Manager/Care Coordinator | 390200000X | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 106S00000X | RBT-19-108654 | CA | Y |
No ID Information.