Provider Demographics
NPI:1174060560
Name:ORTIZ, JOSE (CASAC)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 74TH ST
Mailing Address - Street 2:3FL
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6338
Mailing Address - Country:US
Mailing Address - Phone:718-426-6222
Mailing Address - Fax:
Practice Address - Street 1:3720 74TH ST
Practice Address - Street 2:3FL
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6338
Practice Address - Country:US
Practice Address - Phone:718-426-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY19107101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)