Provider Demographics
NPI:1316405699
Name:ORTIZ, GENNALIS
Entity Type:Individual
Prefix:
First Name:GENNALIS
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 1:6 N MAIN ST STE 110
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-1581
Mailing Address - Country:US
Mailing Address - Phone:585-377-6590
Mailing Address - Fax:
Practice Address - Street 1:6 N MAIN ST STE 110
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1581
Practice Address - Country:US
Practice Address - Phone:585-377-6590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician