Provider Demographics
NPI:1104549252
Name:ORTIZ, LIZ MAREN (EDS)
Entity type:Individual
Prefix:
First Name:LIZ
Middle Name:MAREN
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 OREGON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-4674
Mailing Address - Country:US
Mailing Address - Phone:407-202-9491
Mailing Address - Fax:
Practice Address - Street 1:1525 OREGON AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-4674
Practice Address - Country:US
Practice Address - Phone:407-202-9491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALLMO01129873103T00000X
OR555875103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist