Healthcare Provider Details

I. General information

NPI: 1124763933
Provider Name (Legal Business Name): SUSANA ORTIZ BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 REMINGTON CV
LITTLE ROCK AR
72204-8274
US

IV. Provider business mailing address

5 REMINGTON CV
LITTLE ROCK AR
72204-8274
US

V. Phone/Fax

Practice location:
  • Phone: 501-580-4885
  • Fax: 510-850-8791
Mailing address:
  • Phone: 501-580-4885
  • Fax: 510-850-8791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: