Provider Demographics
NPI:1962908301
Name:ORTIZ, ADRIAN
Entity type:Individual
Prefix:
First Name:ADRIAN
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8270 WILLOW OAKS CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4511
Mailing Address - Country:US
Mailing Address - Phone:703-924-8194
Mailing Address - Fax:
Practice Address - Street 1:8270 WILLOW OAKS CORPORATE DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4511
Practice Address - Country:US
Practice Address - Phone:703-924-8194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS3491811041S0200X
VA3491811041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA101625Medicaid