Provider Demographics
NPI:1497175202
Name:ORTIZ, IVETH A (LBSW)
Entity Type:Individual
Prefix:
First Name:IVETH
Middle Name:A
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E CHISUM ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-5412
Mailing Address - Country:US
Mailing Address - Phone:575-624-6050
Mailing Address - Fax:575-624-6170
Practice Address - Street 1:29 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-6346
Practice Address - Country:US
Practice Address - Phone:575-840-6847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMB-08204104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker