Provider Demographics
NPI:1104236694
Name:ORTIZ, THERESA (LMSW)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10619 VIRGO ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-3661
Mailing Address - Country:US
Mailing Address - Phone:505-366-4942
Mailing Address - Fax:
Practice Address - Street 1:1043 HIGHWAY 313
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-6912
Practice Address - Country:US
Practice Address - Phone:505-867-3351
Practice Address - Fax:505-867-3514
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-08152101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health