Provider Demographics
NPI:1306416938
Name:ORTIZ, JUSTIN RICARDO (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:RICARDO
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7030 ALEXANDRIA JACKSONVLE HWY APT 52
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36265-5632
Mailing Address - Country:US
Mailing Address - Phone:205-363-1862
Mailing Address - Fax:
Practice Address - Street 1:200 CAHABA PARK CIR STE 116
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-5041
Practice Address - Country:US
Practice Address - Phone:205-253-6903
Practice Address - Fax:855-380-3591
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-27
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2021-052103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst