Provider Demographics
NPI:1710445549
Name:ORTIZ-THERIAULT, LUIS ANTONIO
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ANTONIO
Last Name:ORTIZ-THERIAULT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10925 BRIAR FOREST DR APT 1101
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-2215
Mailing Address - Country:US
Mailing Address - Phone:408-888-2479
Mailing Address - Fax:
Practice Address - Street 1:11123 MCCRACKEN CIR STE C
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-4461
Practice Address - Country:US
Practice Address - Phone:281-653-6572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX76893101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health