Provider Demographics
NPI:1588203442
Name:ORTIZ, NICHOLAS GAMALIEL
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:GAMALIEL
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 W SHAW AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3229
Mailing Address - Country:US
Mailing Address - Phone:559-476-2115
Mailing Address - Fax:
Practice Address - Street 1:3433 W SHAW AVE STE 107
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3229
Practice Address - Country:US
Practice Address - Phone:559-558-4051
Practice Address - Fax:559-570-0118
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-24
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor