Provider Demographics
NPI:1700286960
Name:ORTIZ CONCHA, MAX (LISW)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:ORTIZ CONCHA
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 UPTOWN BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4204
Mailing Address - Country:US
Mailing Address - Phone:505-855-9805
Mailing Address - Fax:505-848-9468
Practice Address - Street 1:6400 UPTOWN BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4204
Practice Address - Country:US
Practice Address - Phone:505-855-9805
Practice Address - Fax:505-848-9468
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-068791041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool