Provider Demographics
NPI:1154805653
Name:ORTIZ MONTANEZ, MARIE CARMEN (SSP)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:CARMEN
Last Name:ORTIZ MONTANEZ
Suffix:
Gender:F
Credentials:SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 E 79TH ST APT 5A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-1514
Mailing Address - Country:US
Mailing Address - Phone:787-307-0678
Mailing Address - Fax:
Practice Address - Street 1:1401 AVENUE I
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-3003
Practice Address - Country:US
Practice Address - Phone:718-377-7507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2925771103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty