Provider Demographics
NPI:1205510203
Name:ORTIZ RODRIGUEZ, MIGUEL ANGEL
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:ORTIZ RODRIGUEZ
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 1:27170 SW 134TH PL
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-7792
Mailing Address - Country:US
Mailing Address - Phone:786-624-7469
Mailing Address - Fax:
Practice Address - Street 1:1300 NW 17TH AVE STE 272
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-2562
Practice Address - Country:US
Practice Address - Phone:561-865-7064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician