Provider Demographics
NPI:1457712135
Name:ORTIZ, CHARLIE (LMSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-4221
Mailing Address - Country:US
Mailing Address - Phone:860-841-2345
Mailing Address - Fax:
Practice Address - Street 1:760 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-4221
Practice Address - Country:US
Practice Address - Phone:860-841-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0010041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical