Provider Demographics
NPI:1033747712
Name:ORTIZ, SERGIO IGNACIO JR
Entity Type:Individual
Prefix:MR
First Name:SERGIO
Middle Name:IGNACIO
Last Name:ORTIZ
Suffix:JR
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 1:9702 N SAM HOUSTON PKWY E APT 1133
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396-4550
Mailing Address - Country:US
Mailing Address - Phone:214-254-8245
Mailing Address - Fax:
Practice Address - Street 1:2922 ROSEDALE ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-6188
Practice Address - Country:US
Practice Address - Phone:713-874-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health