Provider Demographics
NPI:1396156030
Name:EDWYN W. ORTIZ-NANCE PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:EDWYN W. ORTIZ-NANCE PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWYN
Authorized Official - Middle Name:W
Authorized Official - Last Name:ORTIZ-NANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-252-6353
Mailing Address - Street 1:2080 N WINERY AVE
Mailing Address - Street 2:#101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-4817
Mailing Address - Country:US
Mailing Address - Phone:559-252-6353
Mailing Address - Fax:559-252-7964
Practice Address - Street 1:2080 N WINERY AVE
Practice Address - Street 2:#101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-4817
Practice Address - Country:US
Practice Address - Phone:559-252-6353
Practice Address - Fax:559-252-7964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94020449302F00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No302F00000XManaged Care OrganizationsExclusive Provider Organization