Provider Demographics
NPI:1326875972
Name:REYES ORTIZ, SHELSIAM A
Entity type:Individual
Prefix:MISS
First Name:SHELSIAM
Middle Name:A
Last Name:REYES ORTIZ
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 1:1142 W 41ST ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4167
Mailing Address - Country:US
Mailing Address - Phone:786-617-0682
Mailing Address - Fax:
Practice Address - Street 1:1142 W 41ST ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4167
Practice Address - Country:US
Practice Address - Phone:786-617-0682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-375972106S00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL124120100Medicaid