Provider Demographics
NPI:1114503000
Name:ORTIZ, TANISHA
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:
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 1:3625 WELSH RD APT L26
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-2935
Mailing Address - Country:US
Mailing Address - Phone:148-493-4824
Mailing Address - Fax:
Practice Address - Street 1:3625 WELSH RD APT L26
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-2935
Practice Address - Country:US
Practice Address - Phone:148-493-4824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician