Provider Demographics
NPI:1184206609
Name:ORTIZ, RACQUEL T
Entity Type:Individual
Prefix:
First Name:RACQUEL
Middle Name:T
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 1:5010 W BROAD ST APT 3407
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-4219
Mailing Address - Country:US
Mailing Address - Phone:843-929-7805
Mailing Address - Fax:
Practice Address - Street 1:5010 W BROAD ST APT 3407
Practice Address - Street 2:
Practice Address - City:SUGAR HILL
Practice Address - State:GA
Practice Address - Zip Code:30518-4219
Practice Address - Country:US
Practice Address - Phone:843-929-7805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC423105203638Medicaid