Provider Demographics
NPI:1063981868
Name:GAYTAN ORTEGA, MAIRA A
Entity type:Individual
Prefix:
First Name:MAIRA
Middle Name:A
Last Name:GAYTAN ORTEGA
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:PO BOX 13463
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88013-3463
Mailing Address - Country:US
Mailing Address - Phone:575-650-0270
Mailing Address - Fax:
Practice Address - Street 1:222 SWANNACK RD
Practice Address - Street 2:
Practice Address - City:VADO
Practice Address - State:NM
Practice Address - Zip Code:88072
Practice Address - Country:US
Practice Address - Phone:575-650-0270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician