Provider Demographics
NPI:1285953513
Name:ORTEGA, MARK ANTHONY (LCSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:ORTEGA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2912 THOMPSON LN SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-4434
Mailing Address - Country:US
Mailing Address - Phone:505-710-5188
Mailing Address - Fax:
Practice Address - Street 1:2716 SAN PEDRO DR NE STE D
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3331
Practice Address - Country:US
Practice Address - Phone:505-710-5188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-094991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM87723042Medicaid