Provider Demographics
NPI:1124244553
Name:ORTIZ, GAEL RAY (LCSW)
Entity type:Individual
Prefix:MR
First Name:GAEL
Middle Name:RAY
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:RAY
Other - Middle Name:
Other - Last Name:ORTIZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1430 COLLIER ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2911
Mailing Address - Country:US
Mailing Address - Phone:512-445-7787
Mailing Address - Fax:512-440-4059
Practice Address - Street 1:56 EAST AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-4323
Practice Address - Country:US
Practice Address - Phone:512-454-3521
Practice Address - Fax:512-703-1390
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX231471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8060N1Medicare ID - Type Unspecified