Provider Demographics
NPI:1457747495
Name:ORTIZ, STACI (PHD)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2574 46TH ST
Mailing Address - Street 2:APT 2
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-1107
Mailing Address - Country:US
Mailing Address - Phone:917-302-5745
Mailing Address - Fax:
Practice Address - Street 1:2574 46TH ST
Practice Address - Street 2:APT 2
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-1107
Practice Address - Country:US
Practice Address - Phone:917-302-5745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020775-1103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent