Provider Demographics
NPI:1093261265
Name:ORTIZ, AMIE NICOLE
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:NICOLE
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5769 CALAIS BLVD N APT 4
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33714-2074
Mailing Address - Country:US
Mailing Address - Phone:407-312-2158
Mailing Address - Fax:
Practice Address - Street 1:5769 CALAIS BLVD N # 4
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33714-2074
Practice Address - Country:US
Practice Address - Phone:407-312-2158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLMH17193101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health