Provider Demographics
NPI:1316606874
Name:RODARTE, MOISES ORTIZ
Entity type:Individual
Prefix:
First Name:MOISES
Middle Name:ORTIZ
Last Name:RODARTE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4170 S DECATUR BLVD STE C1
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-5863
Mailing Address - Country:US
Mailing Address - Phone:702-659-8827
Mailing Address - Fax:
Practice Address - Street 1:4170 S DECATUR BLVD STE C1
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-5863
Practice Address - Country:US
Practice Address - Phone:702-659-8827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVIC-2635102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst