Provider Demographics
NPI:1114609955
Name:ORTIZ, DIVINE UNIVERSE
Entity Type:Individual
Prefix:
First Name:DIVINE
Middle Name:UNIVERSE
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DIVINE
Other - Middle Name:UNIVERSE
Other - Last Name:ORTIZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRPA
Mailing Address - Street 1:79A UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-1336
Mailing Address - Country:US
Mailing Address - Phone:917-536-5765
Mailing Address - Fax:
Practice Address - Street 1:79A UTICA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-1336
Practice Address - Country:US
Practice Address - Phone:917-536-5765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty