Provider Demographics
NPI:1629588413
Name:ORTIZ, JOSE A (BCABA)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1057
Mailing Address - Street 2:
Mailing Address - City:LAKE ALFRED
Mailing Address - State:FL
Mailing Address - Zip Code:33850-1057
Mailing Address - Country:US
Mailing Address - Phone:863-551-3300
Mailing Address - Fax:
Practice Address - Street 1:202 HOWARD ST STE 3
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823-3431
Practice Address - Country:US
Practice Address - Phone:863-551-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-02-0495106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst