Provider Demographics
NPI:1427400381
Name:ORTIZ, MARCO ANTONIO (BA)
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:ANTONIO
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 E MONTE VISTA RD APT C1
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1457
Mailing Address - Country:US
Mailing Address - Phone:323-698-4138
Mailing Address - Fax:
Practice Address - Street 1:302 E MONTE VISTA RD APT C1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1457
Practice Address - Country:US
Practice Address - Phone:323-698-4138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-04
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-000451103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst