Provider Demographics
NPI:1194731844
Name:ORTIZ, MAYRA ZOE (PHD)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:ZOE
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 HAMILTON AVE
Mailing Address - Street 2:1102
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-1807
Mailing Address - Country:US
Mailing Address - Phone:917-363-5706
Mailing Address - Fax:
Practice Address - Street 1:445 HAMILTON AVE
Practice Address - Street 2:1102
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-1807
Practice Address - Country:US
Practice Address - Phone:917-363-5706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY15769103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02720547Medicaid
NY02720547Medicaid