Provider Demographics
NPI:1205050556
Name:ORTIZ, THERESA DIANNE CABALLERO (LICSW)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:DIANNE CABALLERO
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10265 SW WALNUT STREET
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9300 NE OAK VIEW DR
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6347
Practice Address - Country:US
Practice Address - Phone:360-567-2211
Practice Address - Fax:360-567-2212
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW 605418481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical