Provider Demographics
NPI:1104642446
Name:ORTIZ, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:AARON
Other - Middle Name:
Other - Last Name:ORTIZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10401 CALLE HERMOSA CT NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114
Mailing Address - Country:US
Mailing Address - Phone:505-410-5549
Mailing Address - Fax:
Practice Address - Street 1:10401 CALLE HERMOSA CT NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114
Practice Address - Country:US
Practice Address - Phone:505-410-5549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician