Provider Demographics
NPI:1134778202
Name:FORTICH, CATALINA
Entity type:Individual
Prefix:
First Name:CATALINA
Middle Name:
Last Name:FORTICH
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 1:4789 SW 148TH AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-2119
Mailing Address - Country:US
Mailing Address - Phone:786-413-8060
Mailing Address - Fax:
Practice Address - Street 1:4789 SW 148TH AVE
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-2119
Practice Address - Country:US
Practice Address - Phone:786-413-8060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3627101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMT3627OtherFLORIDA DEPARTMENT OF HEALTH