Provider Demographics
NPI:1093572810
Name:ORTEGA GAVIDIA, MONICA SOFHIA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:SOFHIA
Last Name:ORTEGA GAVIDIA
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 1:4580 THOREAU PARK DR APT 202
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-6099
Mailing Address - Country:US
Mailing Address - Phone:407-676-2876
Mailing Address - Fax:
Practice Address - Street 1:2930 LOOPDALE LN
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-7658
Practice Address - Country:US
Practice Address - Phone:407-308-5240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23315255106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician