Provider Demographics
NPI:1811073919
Name:ORTIZ, MIRIAM M (LBSW)
Entity type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:M
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BREAKERS PT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-1336
Mailing Address - Country:US
Mailing Address - Phone:210-724-2639
Mailing Address - Fax:
Practice Address - Street 1:11 BREAKERS PT
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-1336
Practice Address - Country:US
Practice Address - Phone:210-724-2639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29071171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172459301Medicaid