Provider Demographics
NPI:1417415464
Name:ORTIZ THAYNE, WANDA SOCORRO (LCSW)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:SOCORRO
Last Name:ORTIZ THAYNE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:S
Other - Last Name:ORTIZ CAMINITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4199 SPRUCE WOOD DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45432-4124
Mailing Address - Country:US
Mailing Address - Phone:808-295-7362
Mailing Address - Fax:
Practice Address - Street 1:4199 SPRUCE WOOD DR
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-4124
Practice Address - Country:US
Practice Address - Phone:808-295-7362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC63071041C0700X
CALCSW131321041C0700X
UT981962735011041C0700X
NMC21541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical