Provider Demographics
NPI:1104204163
Name:ORTIZ, SAMANTHA (CASAC-T)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 WISNER AVE
Mailing Address - Street 2:APT 4
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-3832
Mailing Address - Country:US
Mailing Address - Phone:845-794-8080
Mailing Address - Fax:848-794-8343
Practice Address - Street 1:396 BROADWAY
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-1157
Practice Address - Country:US
Practice Address - Phone:845-794-8080
Practice Address - Fax:848-794-8343
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31084101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)