Provider Demographics
NPI:1437342300
Name:ORTIZ, SHAUNA NICOLE (MED, LPC)
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:NICOLE
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3129 LAZY PALM DR N
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78552-4218
Mailing Address - Country:US
Mailing Address - Phone:956-536-5551
Mailing Address - Fax:
Practice Address - Street 1:3129 LAZY PALM DR N
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78552-4218
Practice Address - Country:US
Practice Address - Phone:956-536-5551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2008-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61516101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138708611Medicaid