Provider Demographics
NPI:1588085401
Name:ORTIZ, DEANNA (ATC)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 MALVERN ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-5133
Mailing Address - Country:US
Mailing Address - Phone:651-276-6873
Mailing Address - Fax:
Practice Address - Street 1:5803 NEAL AVE N
Practice Address - Street 2:
Practice Address - City:OAK PARK HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55082-2177
Practice Address - Country:US
Practice Address - Phone:651-439-8807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24652255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer