Provider Demographics
NPI:1609358621
Name:ORTIZ DOUGLAS, MARIBEL
Entity Type:Individual
Prefix:
First Name:MARIBEL
Middle Name:
Last Name:ORTIZ DOUGLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CHICOPEE HIGH SCHOOL
Mailing Address - Street 2:820 FRONT STREET
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01020
Mailing Address - Country:US
Mailing Address - Phone:413-594-3437
Mailing Address - Fax:
Practice Address - Street 1:CITY OF CHICOPEE
Practice Address - Street 2:80 CHURCH STREET
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01020-0102
Practice Address - Country:US
Practice Address - Phone:413-594-3437
Practice Address - Fax:413-594-3500
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1104301041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110025828CMedicaid