Provider Demographics
NPI:1609237189
Name:ORTIZ, PENNIE C (CASAC)
Entity Type:Individual
Prefix:
First Name:PENNIE
Middle Name:C
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 ARTIST DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-1308
Mailing Address - Country:US
Mailing Address - Phone:631-727-0710
Mailing Address - Fax:
Practice Address - Street 1:240 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2841
Practice Address - Country:US
Practice Address - Phone:631-727-0710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9638101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)