Provider Demographics
NPI:1023737608
Name:ORTEGA, FABIAN
Entity type:Individual
Prefix:
First Name:FABIAN
Middle Name:
Last Name:ORTEGA
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 1:1171 NE 166TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-3810
Mailing Address - Country:US
Mailing Address - Phone:786-356-0641
Mailing Address - Fax:
Practice Address - Street 1:815 NW 57TH AVE STE 400
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-2042
Practice Address - Country:US
Practice Address - Phone:786-693-6500
Practice Address - Fax:786-703-3424
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT22230340106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician