Provider Demographics
NPI:1629831557
Name:PUERTAS ORTEGA, ROXANA
Entity Type:Individual
Prefix:
First Name:ROXANA
Middle Name:
Last Name:PUERTAS ORTEGA
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 1:3217 15TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33976-2921
Mailing Address - Country:US
Mailing Address - Phone:239-309-4901
Mailing Address - Fax:
Practice Address - Street 1:8359 BEACON BLVD STE 416
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3065
Practice Address - Country:US
Practice Address - Phone:800-920-1927
Practice Address - Fax:305-508-6697
Is Sole Proprietor?:No
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23317485106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician