Provider Demographics
NPI:1669828182
Name:ORTIZ GONZALEZ, DAVID JOHN (MSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOHN
Last Name:ORTIZ GONZALEZ
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB BRISAS DE MAR CHIQUITA
Mailing Address - Street 2:269 CALLE BALLENA
Mailing Address - City:MANATI
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00674
Mailing Address - Country:UM
Mailing Address - Phone:787-340-4332
Mailing Address - Fax:
Practice Address - Street 1:269 CALLE BALLENA
Practice Address - Street 2:URB BRISAS DE MAR CHIQUITA
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-340-4332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-13
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22193320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness